DIPLOMA IV KEBIDANAN

POLITEKNIK KARYA
HUSADA JAKARTA

MANAJEMEN KEBIDANAN PADA AKSEPTOR KB

I. PENGKAJIAN
A. Identitas / biodata
Nama Klien : ___________________ Nama Suami : ___________________
Umur : ___________________ Umur : ___________________
Agama : ___________________ Agama : ___________________
Pendidikan : ___________________ Pendidikan : ___________________
Kebangsaan / Suku : ___________________ Kebangsaan / Suku : ___________________
Pekerjaan : ___________________ Pekerjaan : ___________________
Alamat Kantor : ___________________ Alamat kantor : ___________________
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Alamat Rumah : ________________________________________________________
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B. Anamnesa pada tanggal : __________________________ Pukul : ________________________

1. Riwayat Perkawinan
Kawin . kali, kawin pertama kali umur . tahun
Dengan suami sekarang sudah . Tahun

2. Riwayat Haid
Menarche umur .. tahun, siklus .... hari, HPHT
Teratur / tidak, sakit / tidak, lamanya ... hari
Sifat darah : encer / gumpalan, bau
Fluor albus : ..

3. Riwayat obstetric
1. Jumlah anak lahir hidup : __________________________________________
2. Jumlah anak meninggal : __________________________________________
3. Jenis kelamin anak yang dilahirkan : __________________________________________
4. Persalinan terakhir : __________________________________________
5. Jenis persalinan : __________________________________________
6. Komplikasi : __________________________________________
7. Keadaan Nifas terakhir : __________________________________________

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 4. Riwayat Keluarga Berencana
Macam peserta Keluarga Berencana
a. Baru
b. Sesudah bersalin / keguguran
c. Pernah pakai alat KB
d. Cara KB terakhir ( bagi peserta KB )
e. Keluhan selama pemakaian alat kontrasepsi :
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5. Riwayat Penyakit yang lalu dan sekarang

a. Hepatitis : __________________________________________
b. Diabetes Melitus : __________________________________________
c. Penyakit jantung : __________________________________________
d. Kelaian pembekuan darah : __________________________________________
e. Radang Orchitis : __________________________________________
f. Hipertensi : __________________________________________
g. Adnexitis : __________________________________________
h. Endometriosis : __________________________________________
i. Ekstrimitis
1. Oedema : __________________________________________
2. Varises : __________________________________________

C. Pemeriksaan Fisik
1. Pemeriksaan Umum
a. Kesadaran : __________________________________________
b. Tekanan darah : __________________________________________
c. Suhu : __________________________________________
d. Respirasi : __________________________________________
e. Tinggi badan : __________________________________________
f. Berat badan : __________________________________________

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2. Pemeriksaan sitsematis
a. Kepala
- Muka : ..
- Mata : Conjungtiva : sklera :
b. Leher
- Kelenjar gondok / thyroid ..
- Tumor
c. Dada dan Axilla
- Mammae : membesar , Tumor ., Simetris ..
- Axilla : Tumor ., Nyeri
d. Abdomen
- Jaringan Parut / post operasi
- Palpasi .
e. Ano genitalia
1). Keadaan Vulva / Vagina
- Perdarahan
- Fluor Albus ..
2). Inspeculo : portio :
- luka / tidak ..
- Erosi
- Tanda tanda radang .
3). Periksa dalam
- Keadaan vagina ..
- Portio ..
- pembesaran .
- Posisi ..
- nyeri tekan / goyang ...
- Vulva : Varises / tidak
f. Tungkai : Varises / tidak ..

3. Pemeriksaan Penunjang
a. Hb : gr %
b. PPT :
c. Pap Smear :

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II ANALISA MASALAH / INTERPRETASI DATA DASAR

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III . MASALAH POTENSIAL

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IV. TINDAKAN SEGERA
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V. PERENCANAAN TINDAKAN
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VI PELAKSANAAN TINDAKAN
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 VII EVALUASI
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