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ASUHAN KEBIDANAN KELUARGA BERENCANA
PADA NY ‘ ‘ AKSEPTOR SUNTIKAN 3 BULANAN

DI PUSKESMAS MUARA WAHAU I
No Register : ……………………………………………….
Tanggal Kunjungan : ……………………………………………….
Tanggal Pengkajian : ……………………………………………….
STEP I. IDENTIFIKASI DASAR

A. Identifikasi Istri / Suami
Nama Ibu :................................. Nama Suami :...............................
Umur :................................. Umur :...............................
Agama :................................. Agama :...............................
Suku :................................. Suku :...............................
Pendidikan :................................. Pendidikan :...............................
Alamat :................................. Alamat :...............................
B. Keluhan Utama
1. ..................................................................................................................................
..................................................................................................................................
2. ..................................................................................................................................
..................................................................................................................................
C. Riwayat Keluhan Utama
1. ……………………………………………………………………………………………………………………………..
2. .…...……………………………………………………………………………………………………………………….
3. ………………………………………………………………………………………………………………………….....
D. Riwayat Reproduksi
Menarche :.....................................Warna :..................................
Siklus Haid :.....................................Jumlah :..................................
Lamanya :.....................................Dismenorhoe:..................................
E. Riwayat Perkawinan
Kawin :.....................................
Lamanya :.....................................
Umur waktu nikah :.....................................
F. Riwayat Obstetri
NO GPA JENIS PENOLONG TAHUN BB/PB Bayi
PERSALINAN PERSALINAN
1 ..................... ...................... ................... ..................... ......................
2 ..................... ...................... ................... ..................... ......................
3 ..................... ...................... ................... ..................... ......................
4 ..................... ...................... ................... ..................... ......................
5 ..................... ...................... ................... ..................... ......................
G. Riwayat KB
Jenis Kontrasepsi yang digunakan : .....................................................................
Keluhan Penggunaan Kontrasepsi : …………………………………………………………………
.................................................................................................................................
H. DATA KESEHATAN
1. Riwayat Penyakit yang diderita
- Penyakit menular (HIV/AIDS, TBC, sifilis) : ada / tidak ada
- Penyakit keturunan ( Hypertensi,Jantung,Ginjal) : ada / tidak ada
2. Riwayat Penyakit Keluarga/Ketururnan
3. Riwayat Operasi yang pernah dijalani
- SC : pernah / tidak pernah
- Operasi Kista/Mioma : pernah / tidak pernah
4. Riwayat Keluarga
- Gemelli : ada / tidak ada
I. DATA KEBIASAAN SEHARI-HARI
1. Pola Nutrisi
: ................................................................................................................................
................................................................................................................................
2. Pola Istirahat dan Aktivitas
: .................................................................................................................................
.................................................................................................................................
3. Pola Eliminasi
: ................................................................................................................................
................................................................................................................................
4. Personal Higiene
: ................................................................................................................................
.................................................................................................................................
J. DATA PSIKOSOSIAL
Hubungan dengan Suami : baik / tidak baik
Hubungan dengan keluarga : baik / tidak baik
Adat / kebiasaan yang mempengaruhi kehamilan : ada / tidak ada
Kebiasaan merokok dan minum minuman keras : ada / tidak ada
Tempat Persalinan : Rumah / Puskesmas / Rumah Sakit
I. DATA OBJEKTIF
A. Pemeriksaan umum
Keadaan umum : .............................. Kesadaran : .....................
LILA : .................. cm BB sebelum hamil : ................ kg
Tinggi Badan : .................. cm BB Setelah hamil : ................ kg
B. Tanda-Tanda Vital
Tekanan Darah : .................. mmHg Pernafasan : .............. x/m
Suhu : .................. ° C Nadi : .............. x/m
C. Pemeriksaan Fisik
1. Inspeksi
- Kepala
Rambut : .........................................................................................................
Mata : .........................................................................................................
Hidung : .........................................................................................................
Mulut : .........................................................................................................
Muka : .........................................................................................................
- Leher
Pembengkakan kelenjar tiroid : ada / tidak ada
Pembesaran vena jugularis : ada / tidak ada
Pembesaran Kelenjar Linfe : ada / tidak ada
- Dada
Tarikan dada : ada / tidak ada
Bunyi dada : ada / tidak ada
- Payudara
Mammae : .............................................................................................
Areola mammae : .............................................................................................
Puting susu : .............................................................................................
- Abdomen
Pembesaran : Simetris / tidak simetris
Striae Livide : ada / tidak ada
Linea nigra : ada / tidak ada
Linea Albicans : ada / tidak ada
Bekas Operasi : ada / tidak ada
- Genitalia Eksterna
Lokhia : .............................................................................................
Perineum : .............................................................................................
Edema : .............................................................................................
2. Palpasi Abdomen
TFU : .............................................................................................
Uterus : .............................................................................................
3. Perkusi
Refleks Patella ka / ki : .............................................................................................
PADA NY ‘ ‘ AKSEPTOR SUNTIKAN 1 BULANAN
No Register : ……………………………………………….

Umur :................................. Umur :...............................
Agama :................................. Agama :...............................
Suku :................................. Suku :...............................
Alamat :................................. Alamat :...............................
B. Keluhan Utama
1. ...................................................................................................................................
.................................................................................................................................
2. ...................................................................................................................................
.................................................................................................................................
1. ……………………………………………………………………………………………………………………………..
2. .…...……………………………………………………………………………………………………………………….
3. ………………………………………………………………………………………………………………………….....
Menarche : ...................................... Warna :..................................
Siklus Haid :..................................... Jumlah :..................................
Lamanya :..................................... Dismenorhoe :..................................
Kawin :.....................................
Lamanya :.....................................
Umur waktu nikah :.....................................
F. Riwayat Obstetri
1 ..................... ...................... ................... ..................... ......................
2 ..................... ...................... ................... ..................... ......................
3 ..................... ...................... ................... ..................... ......................
4 ..................... ...................... ................... ..................... ......................
5 ..................... ...................... ................... ..................... ......................
G. Riwayat KB
.................................................................................................................................
H. DATA KESEHATAN
4. Riwayat Keluarga
1. Pola Nutrisi
: .................................................................................................................................
................................................................................................................................
: .................................................................................................................................
.................................................................................................................................
4. Pola Eliminasi
: ................................................................................................................................
................................................................................................................................
5. Personal Higiene
: ................................................................................................................................
.................................................................................................................................
J. DATA PSIKOSOSIAL
II. DATA OBJEKTIF

K. Pemeriksaan umum
L. Tanda-Tanda Vital
Suhu : .................. ° C Nadi : .............. x/m
M. Pemeriksaan Fisik
4. Inspeksi
- Kepala
Rambut : .........................................................................................................
Mata : .........................................................................................................
Hidung : .........................................................................................................
Mulut : .........................................................................................................
Muka : .........................................................................................................
- Leher
- Dada
- Payudara
Mammae : .............................................................................................
Areola mammae : .............................................................................................
Puting susu : .............................................................................................
- Abdomen
Lokhia : .............................................................................................
Perineum : .............................................................................................
Edema : .............................................................................................
5. Palpasi Abdomen
TFU : .............................................................................................
Uterus : .............................................................................................
6. Perkusi
PADA NY ‘ ‘ AKSEPTOR IMPLANT
No Register : ……………………………………………….

Umur :................................. Umur :...............................
Agama :................................. Agama :...............................
Suku :................................. Suku :...............................
Alamat :................................. Alamat :...............................
B. Keluhan Utama
1. ...............................................................................................
...............................................................................................
......................................................................
2. ...............................................................................................
...............................................................................................
......................................................................
7. ……………………………………………………………………………………………………………………………..
8. .…...……………………………………………………………………………………………………………………….
9. ………………………………………………………………………………………………………………………….....
Menarche :.....................................Warna :..................................
Siklus Haid :.....................................Jumlah :..................................
Lamanya :.....................................Dismenorhoe:..................................
Kawin :.....................................
Lamanya :.....................................
Umur waktu nikah :.....................................
F. Riwayat Obstetri
1 ..................... ...................... ................... ..................... ......................
2 ..................... ...................... ................... ..................... ......................
3 ..................... ...................... ................... ..................... ......................
4 ..................... ...................... ................... ..................... ......................
5 ..................... ...................... ................... ..................... ......................
G. Riwayat KB
.................................................................................................................................
H. DATA KESEHATAN
9. Riwayat Keluarga
10. Pola Nutrisi
: ................................................................................................................................
................................................................................................................................
: .................................................................................................................................
.................................................................................................................................
12. Pola Eliminasi
: ................................................................................................................................
................................................................................................................................
13. Personal Higiene
: ................................................................................................................................
.................................................................................................................................
J. DATA PSIKOSOSIAL
III. DATA OBJEKTIF

K. Pemeriksaan umum
L. Tanda-Tanda Vital
Suhu : .................. ° C Nadi : .............. x/m
M. Pemeriksaan Fisik
10. Inspeksi
- Kepala
Rambut : .........................................................................................................
Mata : .........................................................................................................
Hidung : .........................................................................................................
Mulut : .........................................................................................................
Muka : .........................................................................................................
- Leher
- Dada
- Payudara
Mammae : .............................................................................................
Areola mammae : .............................................................................................
Puting susu : .............................................................................................
- Abdomen
Lokhia : .............................................................................................
Perineum : .............................................................................................
Edema : .............................................................................................
11. Palpasi Abdomen
TFU : .............................................................................................
Uterus : .............................................................................................
12. Perkusi

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ASUHAN KEBIDANAN KELUARGA BERENCANA

PADA NY ‘ ‘ AKSEPTOR SUNTIKAN 3 BULANAN

STEP I. IDENTIFIKASI DASAR

STEP I. IDENTIFIKASI DASAR

II. DATA OBJEKTIF

STEP I. IDENTIFIKASI DASAR

III. DATA OBJEKTIF

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