AKADEMI KEBIDANAN (AKBID) BINA HUSADA

Jl. Raya Serang – Jakarta, Km 5 Kp. Malandang, serang

Ijin MENDIKNAS RI No. 137/D/O/2007 dan Ijin DEPKES RI No. HK.03.2.4.1.02638
Tel : (0254) 282054 http://binahusada.akbid.info Serang, Banten

Nama :…………………………………………………….
NIM :…………………………………………………….
Tingkat / Semester :…………………………………………………….
Tempat Praktik :…………………………………………………….

MANAJEMEN KEBIDANAN PADA KELUARGA BERENCANA (KB)

Tanggal Masuk :
No. Register :

I. PENGKAJIAN
A. Data subjektif

1. Identitas :

Nama klien : ................................................................

Umur : ................................................................

Status : ................................................................

Agama : ................................................................

Pendidikan : ................................................................

Pekerjaan : ................................................................

Alamat : ................................................................

Nama suami : ................................................................

Umur : ................................................................

Agama : ................................................................

Pendidikan : ................................................................

Pekerjaan : ...............................................................

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2. Pengkajian Tanggal
a. Alasan datang ke klinik KB : ...............................................................
Yang mengantar : ...............................................................
b. Riwayat Mentruasi : ................................................................
- Menarche : ................................................................
- Siklus : ................................................................
- Lamanya : ................................................................
- Banyaknya : ................................................................
- Sifat darah : ................................................................
- Warna : ................................................................
- HPHT : ................................................................
c. Riwayat perkawinan
- Kawin ke : ................................................................
- Lama perkawinan : ................................................................

d. Riwayat obstetric yang lalu

 Riwayat seluruh kehamilan
- Gravida : ............................... Kali
- Partus : ............................... Kali
- Abortus : ............................... Kali
- Lahir hidup : ............................... Orang
- Lahir mati : ............................... Orang
 Riwayat persalinan Terakhir / Abortus Terakhir
- Tanggal persalinan Terakhir : .............................................
- Jenis persalinan : .............................................
- Apakah sedang menyusui : .............................................

e. Riwayat KB sebelumnya
- Dalam dua tahun terakhir apakah ada memakai kontrasepsi : ya / tidak
Bila ya , jelaskan masing – masing : …………………………………………

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 NO METODE LAMA ALASAN BERHENTI
PEMAKAIAN METODE
KONTRASEPSI
1. PIL
2. IUD
3. SUNTIK
4. KONDOM
5. DLL

f. Riwayat Medis sebelumnya

- Sedang mendapatkan pengobatan jangka panjang : Ya / Tidak
Jika Ya, jelaskan : ………………………………………………………………
- Saat ini sedang menderita penyakit kronis : Ya / Tidak
Jika Ya, jelaskan : ……………………………………………………………

g. Riwayat sosial
- Merokok : ya / tidak, banyaknya……….. batang / hari
- Minuman keras : ya / tidak, banyaknya……….. /hari

h. Riwayat ginekologi
- Tumor ginekologi : ...................................
- Operasi ginekologi yang pernah di alami : ...................................
- Penyakit kelamin : ...................................
 Gonore :............................................................
 Sifilis :............................................................
 Herpes :............................................................
 Keputihan :............................................................
- Perdarahan tanpa sebab yang jelas : ..................................................

B. Data Objektif
Pemeriksaan fisik
1. Status generalis
a. Keadaan umum : .....................................................................
- Tinggi badan : .....................................................................
- Berat badan : .....................................................................
- Nadi : .....................................................................

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 - Respirasi : .....................................................................
- Suhu : .....................................................................
- Tekanan darah : .....................................................................

2. Pemeriksaan khusus obstetri

 Axilla
- Ada benjolan : ada / tidak ada
- Nyeri tekan : ada / tidak ada
- Pembengkakan kelenjar getah bening : ada / tidak ada
 Payudara
- Ada benjolan : ada / tidak ada
- Nyeri tekan : ada / tidak ada
 Pemeriksaan lengan atas : ada luka parut / tidak ada
 Abdomen :
- Pembesaran : ada / tidak ada
 Pemeriksaan vagina
- Pemeriksaan Dalam
 Tumor : ada / tidak ada
 Posisi Rahim : antefleksi / retrofleksi
 Gerakan serviks bebas : ya / tidak
 Perlunakan serviks : lunak / tidak lunak
- Inspekulo
 Tanda – tanda peradangan : ada / tidak ada
 Tanda – tanda kehamilan : ada / tidak ada
 Pendarahan : ada / tidak ada
 Varices : ada / tidak ada
 Erosi : ada / tidak ada
 Lesi : ada / tidak ada
 Panjang uterus : cm
C.Data psikologis :
 Pengertian ibu tentang efek samping alat kontrasepsi : Ya / Tidak
 Pengaruh alat kontrasepsi dengan agama yang di anut : Ya / Tidak
 Pengaruh alat kontrasepsi dengan hubungan suami istri : Ya / Tidak

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 II. INTERPRETASI DATA
Diagnosa Kebidanan :
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Dasar:
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III. IDENTIFIKASI DIAGNOSA / MASALAH POTENSIAL

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IV. TINDAKAN SEGERA / KOLABORASI / RUJUKAN

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 V. PERENCANAAN TINDAKAN
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VI. PELAKSANAAN
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VII. EVALUASI
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 Disetujui Serang, …………………
Pembimbing Akademik

(…………………………) (………………………)
Nama Mahasiswa

Diketahui
Pembimbing Lahan Praktik

( ……………………………….)

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