ASUHAN KEBIDANAN KOMPREHENSIF PADA NY. X UMUR ....

TAHUN
DI ..................

Untuk memenuhi penugasan

Mata Kuliah Praktik Klinik Kebidanan Komprehensif
Program Studi Diploma IV Kebidanan

Disusun Oleh :
DELIMA KHURNIAWATI
NIM : P174243100001

PRODI D.IV KEBIDANAN SEMARANG KELAS

KERJASAMA DINKES KAB. BLORA
JURUSAN KEBIDANAN POLITEKNIK KESEHATAN KEMENKES SEMARANG
2016

HALAMAN PENGESAHAN
Laporan dengan judul Asuhan Kebidanan Komprehensif pada Ny. X umur ..... tahun di .....
telah dilakukan bimbingan dan ujian pada tanggal ..... dan dinyatakan telah memenuhi syarat
untuk diterima.

Semarang, ...............................
Diperiksa Oleh :
Ketua Program Studi DIV Kebidanan Pembimbing dan Penguji
Semarang

......................................
Triana Sri Hardjanti, M.Mid NIP. ...................................
NIP. 19670317 198903 2 002

Mengetahui
Ketua Jurusan Kebidanan
Poltekkes Kemenkes Semarang

Runjiati, M.Mid
NIP. 19741114 199803 2 001
 DAFTAR TABEL

Tabel 1. Jadwal Pemberian Makan pada Bayi

Tabel 2. Nilai Gizi dalam ASI

DAFTAR GAMBAR

Gambar 1. Fisiologi Laktasi

Gambar 2. Sikuls Hormon dalam Laktasi

DAFTAR LAMPIRAN

Lampiran 1 : SAP Penyuluhan Gizi Ibu Menyusui

Lampiran 2 : SAP Penyuluhan Tanda Bahaya pada Ibu Nifas
Lampiran 3 : Curriculum Vitae
Lampiran 2. Format Laporan Asuhan Kehamilan

ASUHAN KEBIDANAN PADA IBU HAMIL FISIOLOGIS

PADA NY. ..... USIA ..... TAHUN G... P... A... USIA HAMIL .... MGG
DENGAN .............................................
DI ...............................................

a PENGKAJIAN :
Tanggal : ......................................... Jam : ........................
b IDENTITAS PASIEN :
Identitas Pasien Penanggung Jawab
Status : Suami / ...............
1 Nama : ..................... 1. Nama : .....................
2 Umur : ..................... 2. Umur : .....................
3 Agama : ..................... 3. Agama : .....................
4 Pendidikan : ..................... 4. Pendidikan : .....................
5 Pekerjaan : ..................... 5. Pekerjaan : .....................
6 Suku Bangsa : ..................... 6. Suiku Bangsa : .....................
7 Alamat : ..................... 7. Alamat : .....................

c DATA SUBYEKTIF
1 ALASAN DATANG
...................................................................................................................
...................................................................................................................
2 KELUHAN UTAMA
...................................................................................................................
...................................................................................................................
Uraian Keluhan Utama
...................................................................................................................
...................................................................................................................
...................................................................................................................
3 RIWAYAT KESEHATAN
Penyakit/Kondisi yang pernah atau sedang diderita :
...................................................................................................................
...................................................................................................................
...................................................................................................................

Riwayat dalam Keluarga (menular maupun keturunan) :

...................................................................................................................
...................................................................................................................
...................................................................................................................
4 RIWAYAT OBSTETRI
a Riwayat Haid :
Menarche : ...................... Nyeri Haid : ......................
Siklus : ...................... Lama : ......................
Warna darah : ...................... Leukhorea : ......................
b Riwayat Kehamilan sekarang
1 Hamil ke .................. usia ........................... minggu
2 HPKT : ............................................................
3 HPL : ............................................................
4 Gerak Janin
- Pertama kali : ..........................................................................
- Frekuensi dalam 12 jam : ........................................................
5 Tanda bahaya : ................................................................................
6 Kekhawatiran khusus : ...................................................................
.......................................................................................................
7 Imunisasi TT : ...................................................................................
......................................................................................................
8 ANC : ........... x
Riwayat ANC
Suplement & Fe TINDAKAN/
ANC ke Tanggal Tempat MASALAH
(Jenis, Jml, & aturan minum) PENDKES

Catatan : Bisa ditambah sesuai kebutuhan

c Riwayat Kehamilan persalinan dan nifas yang lalu

Kead
anak
Kehamilan Persalinan Nifas
sekara
Tahun ng
Asi
Frek KELUHAN/ JK/B Peny
UK Jenis Penolong Penyulit IMD ekskl
ANC PENYULIT B ulit
usif

5 RIWAYAT KB : Pernah / tidak pernah *)

a jika pernah :
Jenis
Lama Pemakaian Keluhan Alasan dilepas
Kontrasepsi

b Rencana Setelah Melahirkan : ..................................................................

6 POLA PEMENUHAN KEBUTUHAN SEHARI-HARI :

Sebelum hamil :
a Nutrisi
1 Makan
1 Frekuensi makan pokok : ................. x perhari
2 Komposisi
- Nasi : .............. x @ ........... piring (sedang / penuh)
- Lauk : .............. x @ ........... potong (sedang / besar)
jenisnya ............................
- Sayuran : .............. x @ ........... mangkuk sayur ; jenis sayur .................
- Buah : .............. x sehari / seminggu, jenis .............................
- Camilan : .............. x sehari, jenis ............................................
3 Pantangan : .................................. alasan ..................................
.................................. alasan ..................................
2 Minum
a Jumlah total ......... gelas perhari, jenis ..............................................
b Susu ..................... gelas perhari, jenis susu ......................................
3 Perubahan selama hamil ini :
.................................................................................................................
b Eliminasi
1 Sebelum hamil
1 Buang air kecil
- Frekuensi perhari : ............. x; warna ...................................
- Keluhan/masalah : ..................................................................
2 Buang air besar
- Frekuensi perhari : ...... x; warna ....konsistensi lembek/keras *)
- Keluhan/masalah : .................................................................
2 Perubahan selama hamil
ini : .......................................................................................................
...................................................................................................................
c Personal hygiene
1 Sebelum hamil :
- Mandi ......... x sehari
- Keramas .......... x seminggu

- Gosok gigi ......... x sehari

- Ganti pakaian ......... x sehari, celana dalam ................ x sehari
2 Kebiasaan selama hamil
ini : ..........................................................................................................
..................................................................................................................
d Hubungan seksual
1 Sebelum hamil :
- Frekuensi : ............ x seminggu
- Contact bleeding : .....................................................................
- Keluhan lain : ............................................................................
2 Perubahan selama hamil
ini : .........................................................................................................
..................................................................................................................
e Istirahat / tidur
1 Sebelum hamil
 - Tidur malam ................ jam
- Tidur siang ................. jam
- Keluhan / masalah : ...........................................................................
2 Perubahan selama hamil
ini : ..........................................................................................................
..................................................................................................................
f Aktivitas fisik dan olahraga
1 Sebelum hamil :
- Aktivitas fisik (beban pekerjaan) : ..........................................
- Olah raga : jenisnya ........................... frekuensi ........ x seminggu
............................... frekuensi ............x seminggu
2 Perubahan selama hamil ini : ...................................................................
................................................................................................................
g Kebiasaan yang merugikan kesehatan :
1 Merokok : ...........................................................................
2 Minuman beralkohol : ...........................................................................
3 Obat-obatan : ...........................................................................
4 Jamu : ...........................................................................

7. Riwayat Psikososial-spiritual
a Riwayat perkawinan :
1 Status perkawinan : menikah/tidak menikah*), umur waktu menikah : .... th
2 Pernikahan ini yang ke ....... sah / tidak *) lamanya ...............
3 Hubungan dengan suami : baik / ada masalah
b Kehamilan ini diharapkan / tidak *) oleh ibu, suami, keluarga :
Respon & dukungan keluarga terhadap kehamilan ini : ..............................
c Mekanisme koping (cara pemecahan masalah) : .........................................
d Ibu tinggal serumah dengan : .......................................................................
e Pengambilan keputusan utama dalam keluarga : ..........................................
Dalam kondisi emergensi, ibu dapat / tidak *) mengambil keputusan sendiri
f Orang terdekat ibu : ........................................................................................
Yang menemani ibu untuk kunjungan ANC : ...............................................
g Adat istiadat yang dilakukan ibu berkaitan dengan kehamilan : ..................
h Rencana tempat dan penolong persalinan yang diinginkan : ........................
i Penghasilan perbulan :
Rp. ................................................................... Cukup/Tidak Cukup *)
j Praktek agama yang berhubungan dengan kehamilan :
1 Kebiasaan puasa / apakah ibu berpuasa selama hamil ini : ........
Jika ya frekuensi puasa : ....................................................
Keluhan selama puasa : ...........................................................
2 Keyakinan ibu tentang pelayanan kesehatan : ........................
Ibu dapat menerima segala bentuk pelayanan
kesehatan yang diberikan oleh nakes wanita
maupun pria
Tidak boleh menerima transfusi darah
 Tidak boleh diperiksa daerah genitalia
Lainnya : .................................................................
....

k Tingkat pengetahuan ibu :

Hal-hal yang sudah diketahui ibu : .................................................................
.........................................................................................................................
Hal-hal yang ingin diketahui ibu : ..................................................................
.........................................................................................................................

d. DATA OBYEKTIF
1 PEMERIKSAAN FISIK
a Pemeriksaan Umum
1 Keadaan Umum : ................. Tensi : .....................
2 Kesadaran : ................. Nadi : .................
3 BB Sebelum/Sekarang : ................ Suhu/T : .................
4 TB : ................. RR : .................
5 LILA : ................. IMT : .................
b Status Present
Kepala : .................................................................................
Mata : .................................................................................
Hidung : .................................................................................
Mulut : .................................................................................
Telinga : .................................................................................
Leher : .................................................................................
Ketiak : .................................................................................
Dada : .................................................................................
Lipat paha : .................................................................................
Vulva : .................................................................................
Ekstremitas : .................................................................................
Refleks patella : ............ / ..................
Punggung : ................................................................................
Anus : ................................................................................
c Status Obstetrik
1 Inspeksi
- Muka : ...............................................................................
- Mamae : ...............................................................................
- Abdomen : ...............................................................................
- Vulva : ...............................................................................
2 Palpasi
Leoplod I : ................................................................................
..................................................................................
Leoplod II : ................................................................................
..................................................................................
Leoplod III : ...............................................................................
..................................................................................
 Leoplod IV : ................................................................................
..................................................................................
TFU : ......... c. TBJ : ............. gram
3 Auskultasi
DJJ : .................. x/menit Frekuensi : .......-.........-......../.......
2 Pemeriksaan Penunjang
........................................................................................................................
........................................................................................................................
........................................................................................................................ ANALISA
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
PELAKSANAAN Tanggal ............................... Jam ..............
1 ............................................................................................................
Hasil ..................................................................................................
2 ...........................................................................................................
Hasil ..................................................................................................
3 ............................................................................................................
Hasil ..................................................................................................
4 ............................................................................................................
Hasil ..................................................................................................
5 ............................................................................................................
Hasil ..................................................................................................
................,................................2
015
Pembimbing Klinik
Praktikum

______________________
____________________

Mengetahui
Pembimbing Institusi

___________________
 CATATAN PERKEMBANGAN

Nama Pasien : No RM Ruang

Umur Tanggal:
Catatan Perkembangan
Tanggal/Jam : Nama dan Paraf
(SOAP)

Lampiran 3. Format Laporan Asuhan Persalinan

ASUHAN KEBIDANAN PADA IBU HAMIL FISIOLOGIS

 PADA NY. ..... USIA ..... TAHUN G... P... A... USIA HAMIL .... MGG
JANIN ..............., LETAK .................U, PU ..................
INPARTU KALA.....................................

a PENGKAJIAN :
Tanggal : ......................................... Jam : ........................
b IDENTITAS PASIEN :
Identitas Pasien Penanggung Jawab
Status : Suami / ...............
1 Nama : ...................... 1. Nama : ......................
2 Umur : ...................... 2. Umur : ......................
3 Agama : ...................... 3. Agama : ......................
4 Pendidikan : ...................... 4. Pendidikan : ......................
5 Pekerjaan : ...................... 5. Pekerjaan : ......................
6 Suku Bangsa : ...................... 6. Suiku Bangsa : ......................
7 Alamat : ...................... 7. Alamat : ......................

c DATA SUBYEKTIF
1 ALASAN DATANG
...................................................................................................................
...................................................................................................................
...................................................................................................................
2 KELUHAN UTAMA
...................................................................................................................
...................................................................................................................
...................................................................................................................
Uraian Keluhan Utama
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
3 Tanda-Tanda Persalinan
Kontraksi : ............................................. Frekuensi : .........................
Lokasi ketidak nyamanan : ............................................
PPV : ............................................
4 Riwayat Kesehatan
Penyakit/kondisi yang pernah atau sedang diderita :
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
Riwayat dalam Keluarga (menular maupun keturunan) :
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
7 RIWAYAT OBSTETRI
d Riwayat Haid :
Menarche : ...................... Nyeri Haid : ......................
Siklus : ...................... Lama : ......................
Warna darah : ...................... Leukhorea : ......................
Banyaknya : ...............................................................................
e Riwayat Kehamilan sekarang
1 Hamil ke .................. usia ........................... minggu
2 HPHT : ................................... HPL : .........................
3 Gerak Janin
- Pertama kali : ..........................................................................
- Frekuensi dalam 12 jam : ........................................................
4 Tanda bahaya : ................................................................................
5 Kekhawatiran khusus : ...................................................................
......................................................................................................
6 Imunisasi TT : .............................................................................
......................................................................................................
7 ANC : ........... x

8 Pola Pemenuhan Kebutuhan Terakhir Kali :

a Nutrisi
Makan, Jam : ............................................ WIB
1 Komposisi
- Nasi : .............. x @ ........... piring (sedang / penuh)
- Lauk : .............. x @ ........... potong (sedang / besar)
jenisnya ............................
- Sayuran : .............. x @ ........... mangkuk sayur ; jenis
sayur ...................................................................
- Buah : .............. potong, jenis .........................................
- Camilan: .............. x sehari, jenis ............................................
2 Pantangan : .............................. alasan ......................................
.............................. alasan ......................................
Minum, Jam : .......................... WIB
Jenis............................., Jumlah ..............................................gelas
Jenis............................., Jumlah ..............................................gelas
b Pola Istirahat
1 Jam .......................... s.d ......................... WIB
2 Kualitas : .....................................................................................
3 Keluhan/masalah : .........................................................................................
....................................................................................
c Pola aktifitas :
............................................................................................................
d Pola Eliminasi
1 Buang air kecil, Jam : ............................. WIB
a Jumlah : ................................; warna ..................................
b Keluhan/masalah :
.....................................................................................
 2 Buang air besar
a Jumlah : ......................; konsistensi lembek/keras*) .................
b Keluhan/masalah : ...................................................................
e Personal Hygiene
1 Jam : ................. WIB
Mandi Ganti Pakaian
Keramas Ganti Celana Dalam
Gosok Gigi

9 Riwayat Psikososial-spiritual
a Riwayat Perkawinan :
1 Status perkawinan : menikah/tidak menikah *), umur waktu
menikah : .......... th
2 Pernikahan ini yang ke ...... sah/tidak sah*) lamanya : ..............
3 Hubungan dengan suami : baik/ada masalah*)
b Persalinan ini diharapkan/tidak*) oleh ibu, suami, keluarga;
Respon & dukungan keluarga terhadap persalinan ini :
..........................................................................................................
c Mekanisme koping (cara pemecahan masalah) :
............................................................................................................
d Ibu tinggal serumah dengan :
............................................................................................................
e Pengambilan keputusan utama dalam keluarga :
............................................................................................................
Dalam kondisi emergensi, ibu dapat / tidak *) mengambil keputusan sendiri
f Orang terdekat ibu :
............................................................................................................
Yang menemani ibu untuk Persalinan :
............................................................................................................
g Adat istiadat yang dilakukan ibu berkaitan dengan persalinan :
............................................................................................................
h Penghasilan perbulan :
Rp. .............................................................. Cukup/Tidak Cukup *)
i Praktek agama yang berhubungan dengan kehamilan :
............................................................................................................
j Keyakinan ibu tentang pelayanan kesehatan :
............................................................................................................
Ibu dapat menerima segala bentuk pelayanan
kesehatan yang diberikan oleh nakes wanita
maupun pria
Tidak boleh menerima transfusi darah
Tidak boleh diperiksa daerah genitalia
Lainnya : ...............................................................
......

k Tingkat pengetahuan ibu :

Hal-hal yang sudah diketahui ibu :
............................................................................................................
............................................................................................................
Hal-hal yang belum diketahui ibu :
............................................................................................................
............................................................................................................
Hal-hal yang ingin diketahui ibu :
............................................................................................................
............................................................................................................
D. DATA OBYEKTIF
1 PEMERIKSAAN FISIK
a Pemeriksaan Umum
1 Keadaan Umum : ................. Tensi : .....................
2 Kesadaran : ................. Nadi : .................
3 TB : ................ Suhu/T : .................
4 LILA : ................. RR : .................
b Status Present
Kepala : ................................................................................
Mata : ................................................................................
Hidung : ................................................................................
Mulut : ................................................................................
Telinga : ................................................................................
Leher : ................................................................................
Ketiak : ................................................................................
Dada : ................................................................................
Lipat paha : ................................................................................
Vulva : ................................................................................
Ekstremitas : ................................................................................
Refleks patella : ............ / ..................
Punggung : ................................................................................
Anus : ................................................................................ Status
Obstetrik
1 Inspeksi
- Muka : ................................................................................
- Mamae : ................................................................................
- Abdomen : ................................................................................
- Vulva : ................................................................................
 2 Palpasi
Leoplod I : ................................................................................
..................................................................................
Leoplod II : ................................................................................
..................................................................................
Leoplod III : ................................................................................
..................................................................................
Leoplod IV : ................................................................................
..................................................................................
TFU : ......... c. TBJ : ............. gram
3 Auskultasi
DJJ : ................. x/menit Frekuensi : ........-.........-......../.......
2 Pemeriksaan Dalam : tgl/jam : ............................
Vulva/vagina : ....................................
Serviks :
- Posisi : Anterior / Medial / Posterior *)
- Pembukaan : ..................................
- Efficement : ..................................
Kulit Ketuban : ................................................
Presentasi : ................................................
POD (Pointr of direction) : .............................................
Penyusupan : ................................................
Penurunan bag. Terbawah : ...........................................
3 Pemeriksaan Penunjang :
........................................................................................................................
........................................................................................................................
c ANALISA
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
f PELAKSANAAN Tanggal ............................... Jam ..............
1 ..............................................................................................................
Hasil .......................................................................................................
2 ..............................................................................................................
Hasil .......................................................................................................
3 ..............................................................................................................
Hasil .......................................................................................................
4 ..............................................................................................................
Hasil .......................................................................................................
5 ..............................................................................................................
Hasil .......................................................................................................
6 ..............................................................................................................
Hasil .......................................................................................................

................,................................2
015
Pembimbing Klinik
Praktikum

______________________
____________________

Mengetahui
Pembimbing Institusi

___________________
CATATAN PERKEMBANGAN

Nama Pasien : No RM Ruang

Umur Tanggal:
Catatan Perkembangan
Tanggal/Jam : Nama dan Paraf
(SOAP)
Lampiran 4. Format Laporan nifas dan menyusui

LAPORAN
ASUHAN KEBIDANAN PADA IBU NIFAS NORMAL

A PENGKAJIAN :
Tanggal : .........................................
Waktu : .........................................
Tempat : .........................................
Biodata : .........................................
1 Nama : ......................... 1. Nama : .........................
2 Suku Bangsa : ......................... 2. Suku Bangsa : .........................
3 Umur : ......................... 3. Umur : .........................
4 Agama : ......................... 4 Agama : .........................
5 Pendidikan : ......................... 5. Pendidikan : .........................
6 Pekerjaan : ......................... 6. Pekerjaan : .........................
7 Alamat : ......................... 7. Alamat : .........................

B DATA SUBYEKTIF
1 ALASAN DATANG
...................................................................................................................
...................................................................................................................
2 KELUHAN UTAMA
...................................................................................................................
...................................................................................................................
Uraian Keluhan Utama
...................................................................................................................
...................................................................................................................
...................................................................................................................

3 Riwayat Obstetri
a Riwayat Haid :
Menarche : ......................... Nyeri Haid : .........................
Siklus : ......................... Lama : .........................
Warna darah : ......................... Leukhorea : .........................
Banyaknya : .....................................................................................
b Riwayat Persalinan dan Nifas yang lalu
Kead
Persalinan Nifas anak
Tahun sekarang
Asi
UK Jenis Penolong JK/BB Penyulit IMD Penyulit
eksklusif
c Riwayat Persalinan sekarang
Paritas : .................... Abortus : ....................
Tempat persalinan : ............................... Ditolong oleh : ................
Jenis persalinan : ...............................
Masalah dalam persalinan : ...............................
Keadaan Plasenta : ...............................
Keadaan tali pusat : ...............................
Keadaan bayi : ............................... Jenis Kelamin : ..............
Tanggal/Jam Lahir : ............................... Apgar score ...................
BB : .............gr, PB : .......... cm LK : .............. cm, LD : ............ cm
Kelainan bawaan : ...............................
d Riwayat kesehatan :
Penyakit/kondisi yang pernah atau sedang diderita :
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
Riwayat penyakit dalam keluarga (menular maupun keturunan)
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................ Riwayat
KB : Pernah/Tidak Pernah*)
Lama
Alasan
Jenis KB Penggunaa Keluhan
Berhenti
n

e Pola Pemenuhan Kebutuhan Sehari-Hari :

1
Nutrisi
a Makan
Frekuensi makan pokok : ................. x perhari
Komposisi
- Nasi : .............. x @ ........... piring (sedang / penuh)
- Lauk : .............. x @ ........... potong (sedang / besar)
jenisnya ............................
- Sayuran : .............. x @ ........... mangkuk sayur ; jenis
sayuran .................
- Buah : .............. x sehari / seminggu, jenis ..............................
- Camilan: .............. x sehari, jenis .................................................
c Minum
 Jumlah total ..................., gelas perhari; jenis .....................................
Susu ............................... gelas perhari
2 Eliminasi
a Buang air kecil
- Frekuensi perhari : ............. x; warna ...................................
b Keluhan/masalah : ................................................................. Buang air besar
- Frekuensi perhari : ......... x; warna ........................konsistensi lembek /
keras *)
3 Keluhan/masalah : ................................................................. Personal hygiene
- Mandi ......... x sehari
- Keramas .......... x seminggu
- Gosok gigi ......... x sehari
- Ganti pakaian ......... x sehari, celana dalam ................ x sehari
- Kebiasaan memakai alas kaki :
.....................................................................................................................
4 Hubungan seksual
- Frekuensi : ............ x seminggu
- Keluhan lain : ............................................................................
5 Istirahat / tidur
- Tidur malam ................ jam
- Tidur siang ................. jam
- Keluhan / masalah :
..................................................................................................................
6 Aktivitas fisik dan olahraga
- Aktivitas fisik (beban pekerjaan) : ..........................................
- Olah raga : jenisnya ........................... frekuensi ........ x seminggu
............................... frekuensi ............x seminggu
7 Kebiasaan yang merugikan kesehatan :
Merokok :
....................................................................................
Minuman beralkohol :
...................................................................................
Obat-obatan :
....................................................................................
Jamu :
....................................................................................
8 Pola menyusui
................................................................................................................
9 Riwayat Psikososial-spiritual
a Riwayat perkawinan :
Status perkawinan : menikah / tidak menikah*), umur waktu
menikah : ........ th
Pernikahan ini yang ke ....... sah / tidak *) lamanya ...............th
Hubungan dengan suami : baik / ada masalah
b Kehamilan ini diharapkan / tidak *) oleh ibu, suami, keluarga :
Respon & dukungan keluarga terhadap nifas ini : .................................
c Mekanisme koping (cara pemecahan masalah) :
............................................................................................................
d Ibu tinggal serumah dengan :
............................................................................................................
Pengambilan keputusan utama dalam keluarga :
.........................................................................................................
e Dalam kondisi emergensi, ibu dapat / tidak *) mengambil keputusan sendiri
f Orang terdekat ibu :
............................................................................................................
g Yang menemani ibu untuk kunjungan PNC :
...........................................................................................................
h Adat istiadat yang dilakukan ibu berkaitan dengan nifas : .
.............................................................................................................
i Penghasilan perbulan :
Rp. .............................................................. Cukup/Tidak Cukup *)
j Praktek agama yang berhubungan dengan nifas :
............................................................................................................
k Keyakinan ibu tentang pelayanan kesehatan :
............................................................................................................
Ibu dapat menerima segala bentuk pelayanan
kesehatan yang diberikan oleh nakes wanita
maupun pria
Tidak boleh menerima transfusi darah
Tidak boleh diperiksa daerah genitalia
Lainnya : ................................................................
.....

l Tingkat pengetahuan ibu :

Hal-hal yang sudah diketahui ibu :
............................................................................................................
Hal-hal yang belum diketahui ibu :
................................................................................................................. ............
..........................................................................................
............................................................................................................
Hal-hal yang ingin diketahui ibu :
................................................................................................................. ............
..........................................................................................
............................................................................................................
C . DATA OBYEKTIF
1 PEMERIKSAAN FISIK
a Pemeriksaan Umum
1 Keadaan Umum : .................
2 Kesadaran : .................
3 Tensi : .....................
4 Suhu/T : .................
5 Nadi : .................
6 RR : .................
b Status Present
Kepala : ................................................................................
Muka : ................................................................................
Mata : ................................................................................
Hidung : ................................................................................
Mulut : ................................................................................
Telinga : ................................................................................
Leher : ................................................................................
Ketiak : ................................................................................
Dada : ................................................................................
Abdomen : ................................................................................
Lipat paha : ................................................................................
Vulva : ................................................................................
Ekstremitas : ................................................................................
Punggung : ................................................................................
Anus : ................................................................................
 c Status Obstetrik
Muka : ................................................................................
Mamae : ................................................................................
Abdomen : ................................................................................
Genetalia : Lokea ......................................................................
Luka Parenium ........................................................
2 Pemeriksaan Penunjang :
............................................................................................................
............................................................................................................

D ANALISA
........................................................................................................................
........................................................................................................................
........................................................................................................................

E PELAKSANAAN Tanggal ............................... Jam ..............

1 ..............................................................................................................
Hasil .....................................................................................................
2 ..............................................................................................................
Hasil .....................................................................................................
3 ..............................................................................................................
Hasil .....................................................................................................
4 ..............................................................................................................
Hasil .....................................................................................................
5 ..............................................................................................................
Hasil .....................................................................................................
 ................,................................2
015
Pembimbing Klinik
Praktikum

______________________
____________________

Mengetahui
Pembimbing Institusi

___________________
 CATATAN PERKEMBANGAN

NO. RM
RB/BPM Nama Pasien :
Nama Bidan :
CATATAN PERKEMBANGAN
CATATAN PERKEMBANGAN
Tanggal dan jam Nama dan Paraf
(SOAP)

Lampiran 5. Format Laporan Asuhan BBL

LAPORAN
ASUHAN KEBIDANAN PADA BAYI BARU LAHIR NORMAL

I PENGKAJIAN :
Tanggal :
Waktu :
Tempat :
II IDENTITAS :
a Identitas bayu
Nama : .........................
Tanggal/Jam Lahir: .........................
Jenis Kelamin : .........................
b Identitas orang tua
Nama Ibu : ..................... Nama ayah : .....................
Umur : ..................... Umur : ......................
Agama : ..................... Agama : ......................
Pendidikan : ..................... Pendidikan : ......................
Pekerjaan : ..................... Pekerjaan : ......................
Alamat : ..................... Alamat : ......................

III DATA SUBYEKTIF

1 Riwayat kehamilan ibu
a Umur kehamilan: .....................................
b Riwayat penyakit dalam hamil : .......................
c Kebiasaan selama hamil :
Merokok : .....................
Konsumsi alkohol : ................
Jamu-jamuan, narkoba, maupun obat-obatan bebas : ...................
d Riwayat Natal :
Tanggal Lahir :
BB : ........... gram
PB : ............. cm
Jenis Kelamin : .........
Tunggal/Gemelli : ......................
Lama persalinan kala I, kala II : ..................
Komplikas persalinan : .................................
e Riwayat Perinatal : Penilaian Apgar Score
Appeara Grima Activi Respirat
nce Pulse ce ty ory Scora
1 Menit
5 Menit ke-1
5 Menit ke-2

2 Pola kebiasaan sehari-hari

a Pola Nutrisi : ...........................
b Pola eliminasi : ...........................
 c Pola Istirahat : ...........................
d Pola Aktivitas : ...........................
IV DATA OBYEKTIF
1 Pemeriksaan Umum
Keadaan umum : ...........................
Kesadaran : ...........................
Vital sign : N = ...................... x/mnt
RR = ...................... x/mnt
S = ...................... x/mnt
Pengukuran antropometri :
BB : ....................... cm
PB : ....................... cm
Lingkar Kepala : ....................... cm
Lingkar dada : ....................... cm
Lingkar lengan : ....................... cm
2 Status Present
Kepala : ................................................................................
Mata : ................................................................................
Hidung : ................................................................................
Mulut : ................................................................................
Telinga : ................................................................................
Leher : ................................................................................
Dada : ................................................................................
Pulmo/jantung : ................................................................................
Abdomen : ................................................................................
Genetalia : ................................................................................
Punggung : ................................................................................
Anus : ................................................................................
Ekstremitas : ................................................................................
Kulit : ................................................................................
Reflek : ................................................................................
Rooting reflek : ...........................................................................
Sucking reflek : ...........................................................................
Grasp reflek : ...........................................................................
Moro reflek : ...........................................................................
Tonic neck reflek : ...........................................................................
Babinski reflek : ...........................................................................
.
V ANALISA : ....................................

VI PENATA LAKSANAAN
1 ..............................................................................................................
Hasil .......................................................................................................
2 ..............................................................................................................
Hasil .......................................................................................................
3 ..............................................................................................................
Hasil .......................................................................................................
4 ..............................................................................................................
Hasil .......................................................................................................
5 ..............................................................................................................
Hasil .......................................................................................................

Semarang,................................2
015
Pembimbing Klinik
Praktikum

______________________
____________________

Mengetahui
Pembimbing Institusi

___________________
CATATAN PERKEMBANGAN

Nama Pasien : No RM Ruang

Umur Tanggal:
Catatan Perkembangan
Tanggal/Jam : Nama dan Paraf
(SOAP)
 Lampiran 6. Format Laporan Asuhan KB
LAPORAN
ASUHAN KEBIDANAN PADA AKSEPTOR KB ...............

I PENGKAJIAN
Tanggal : .........................
Jam : .........................
Tempat : .........................
II IDENTITAS PASIEN
Identitas Pasien Identitas Suami
Nama : ..................... Nama : .....................
Umur : ..................... Umur : ......................
Agama : ..................... Agama : ......................
Pendidikan : ..................... Pendidikan : ......................
Pekerjaan : ..................... Pekerjaan : ......................
Suku bangsa : ..................... Suku bangsa : .....................
Alamat : ..................... Alamat : ......................

III DATA SUBYEKTIF

1 Alasan Datang : ..........................................................................................

Keluhah Utama : .........................................................................................

2 Riwayat Menstruasi :
Menarche : ...................... Nyeri Haid : ......................
Siklus : ...................... Banyaknya : ......................
Lama : ...................... Warna Darah : ......................
Keluhan : ...................... HPHT : ......................
3 Riwayat Perkawinan : ........................
Umur Waktu Nikah : ...................... Lama Nikah : ......................
Perkawinan ke : ...................... Jumlah anak : ......................
4 Riwayat Kesehatan
Sekarang : .........................................................................................

Yang lalu : ........................................................................................

Keluarga : .........................................................................................

5 Riwayat Kehamilan, Persalinan dan Nifas

Keadaan Anak
Umur
Ana A Jenis Hidup Mati
Kehamil Penolong Komplikasi Nifas BBL
k ke b Partus J
an Umur Umur JK
K
6 Riwayat KB : .......................................................................................
LAMA ALASAN
JENIS KB KELUHAN
PEMAKAIAN BERHENTI

7 Pola Pemenuhan Kebutuhan Sehari-Hari :

Pola Nutrisi :
....................................................................................................................
....................................................................................................................

Pola Eliminasi :
....................................................................................................................
....................................................................................................................
Pola Aktivitas :
....................................................................................................................
....................................................................................................................
Pola Istirahat :
....................................................................................................................
....................................................................................................................
Pola sexual
....................................................................................................................
....................................................................................................................
Pola Hygiene
....................................................................................................................
....................................................................................................................
Psiko, sosial, spiritual, cultural
....................................................................................................................
....................................................................................................................
8 Data Psikologis :
....................................................................................................................
....................................................................................................................
9 Pola Kebiasaan Hidup sehat :
....................................................................................................................
....................................................................................................................
10 Data Psikososial : Hubungan dengan suami/keluarga/masyarakat
....................................................................................................................
....................................................................................................................
....................................................................................................................
 11 Pengetahuan ibu tentang KB (jenis, manfaat dan efek samping)
....................................................................................................................
....................................................................................................................
....................................................................................................................
IV DATA OBYEKTIF
1 Pemeriksaan Umum
Keadaan Umum : ................. Kesadaran : .....................
Tensi : .................mmHg Nadi : ........... x/mnt
0
Suhu/T : ................ C RR : .................
BB Sebelum/Sekarang : ....................
2 Pemeriksaan Fisik
Kepala
: .....................................................................................
Muka
: .....................................................................................
Leher
: .....................................................................................
Dada
: .....................................................................................
Perut
: .....................................................................................
Ekstremitas
: .....................................................................................
Genetalia
: .....................................................................................
Anus
: .....................................................................................
 3 Pemeriksaan Penunjang :
HCG urine : .......................
Hb : ...........................
4 Pemeriksaan Obstetri (Khusus IUD) : Hasil Pemeriksaan Dalam :
...............................................................................................................
...............................................................................................................

V ANALISA
.................................................................................................................

VI PENATALAKSANAAN
1 .........................................................................................................
Hasil :
............................................................................................................
............................................................................................................
2 .........................................................................................................
Hasil :
............................................................................................................
............................................................................................................
3 .........................................................................................................
Hasil :
............................................................................................................
............................................................................................................
 4 .........................................................................................................
Hasil :
............................................................................................................
............................................................................................................
5 .........................................................................................................
Hasil :
............................................................................................................
............................................................................................................

Semarang,................................2
015
Pembimbing Klinik
Praktikum

______________________
____________________

Mengetahui
Pembimbing Institusi

___________________