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No. Register : .................................... Tanggal Pengkajian : …………………

Tanggal masuk : .................................... Waktu Pengkajian : …………………
Waktu masuk : .................................... Tempat Pengkajian : ...........................

A. DATA SUBJEKTIF
1. Identitas Pasien
Nama : Ny. “…” Nama Suami : Tn. “…”
Umur : …. th Umur : …. th
Pekerjaan : .................................... Pekerjaan : .....................................
Agama : .................................... Agama : .....................................
Pendidikan : .................................... Pendidikan : .....................................
Suku / bangsa: ................................... Suku / bangsa : .....................................
Alamat : .................................... Alamat : .....................................
.................................... .....................................
No. HP : .................................... No. HP : .....................................

2. Alasan Kunjungan
........................................................................................................................................
........................................................................................................................................

3. Keluhan Utama
........................................................................................................................................
........................................................................................................................................

4. Riwayat Kesehatan
a. Riwayat Kesehatan Dahulu .....................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ...............................................................................................................
.................................................................................................................................
b. Riwayat Kesehatan Sekarang .................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ..............................................................................................................
.................................................................................................................................
c. Riwayat Kesehatan Keluarga ..................................................................................
Menurun : ...............................................................................................................
.................................................................................................................................
Menular : ................................................................................................................
.................................................................................................................................
Menahun : ..............................................................................................................
.................................................................................................................................
 5. Riwayat Perkawinan
Perkawinan ke ............................. Menikah sejak umur P :…. Th L :…. Th
Lama perkawinan......................... Status perkawinan sah / tidak

6. Riwayat Haid
Manarche : .......... Tahun Banyaknya darah: ........ Ganti pembalut/ Hari
Siklus haid : .......... Hari Konsistensi : .................................................
Lama : .......... Hari Disminorhoe : ............................................
HPHT : ........................... Flour Albus : ............................................
HPL : ...........................

7. Riwayat Obstetric ( ………………………. )

Hamil Persalinan Ket.

ke- Tgl UK Jenis Penolong/ Komp JK BB/TB H/M
Tempat . (usia)

8. Riwayat KB

No Mulai Memakai Berhenti / Ganti Cara

Metode Tanggal Petugas Tempat Tanggal Petugas Tempat Alasan

9. Riwayat Kehamilan Sekarang

ANC .................................................... Sejak umur kehamilan ....................................
Gerakan pertama kali dirasakan pada umur kehamilan ................................................
Gerakan dalam satu hari ................................................................................................
Frekuensi periksa TM I ...................... TM II ...................... TM III ............................
Imunisasi TT .................................................................................................................
 Pendidikan kesehatan yang diperoleh
Trimester Meteri pendidikan kesehatan

I ........................................................................................................
........................................................................................................

II .......................................................................................................
.......................................................................................................

III .........................................................................................................
.........................................................................................................

Permasalahan dan keluhan dalam kehamilan

Trimeste Masalah/ Keluhan Tindakan/ Therapy
r
I ..................................................... ..................................................
.

II ................................................... .......................................................
..

III ..................................................... ....................................................

10. Pola Kebutuhan Sehari-hari

a. Nutrisi
Sebelum hamil :
Makan Teratur / Tidak teratur … kali/hari ………………………………………
Konsumsi air putih ± …… gelas/hari
Tidak ada/ ada masalah
Selama hamil :
Makan Teratur / Tidak teratur … kali/hari ………………………………………
Konsumsi air putih ± …… gelas/hari
Tidak ada/ ada masalah……………………………………………………………
b. Eliminasi
Sebelum hamil :
BAB … kali/hari, Teratur / Tidak teratur
BAK … kali/hari, Lancar / Tidak lancar
Tidak ada/ ada masalah
Selama hamil :
BAB … kali/hari, Teratur / Tidak teratur
BAK … kali/hari, Lancar / Tidak lancar
Tidak ada/ ada masalah……………………………………………………………
 c. Istirahat
Sebelum hamil :
Tidur siang / Tidak tidur siang± … jam
Tidur malam ± ….. jam
Tidak ada/ ada masalah……………………………………………………………
Selama hamil :
Tidur siang / Tidak tidur siang± … jam
Tidur malam ± ….. jam
Tidak ada/ ada masalah……………………………………………………………
d. Aktivitas
Sebelum hamil : Ibu dapat beraktivitas normal/ tidak normal
Selama hamil : Ibu dapat beraktivitas normal/ tidak normal
…………………………………………………………………...………………
e. Personal Hygiene
Sebelum hamil : …………………………………………………………………...
.................................................................................................................................
.................................................................................................................................
Selama hamil : …………………………………………………………………...
.................................................................................................................................
.................................................................................................................................
f. Pola Seksual
Sebelum hamil : …………………………………………………………………...
Selama hamil : ……………………………………………………………………

11. Data Psiko Sosial Spiritual

Tanggapan ibu dan keluarga terhadap kehamilan ini : Ibu dan keluarga menginginkan
dan mendukung kehamilan ini / tidak menginginkan dan mendukung nya
Pengetahuan Ibu dan keluarga terhadap kehamilan ini : Baik / kurang dalam
pengetahuan kehamilan
Pengambilan keputusan oleh : Suami / Ibu / Keluarga
Ketaatan ibu beribadah menganut agama : ……………………………………………..
Ibu tinggal bersama : Keluarga / sendiri
Hewan peliharaan : Tidak memiliki / memiliki…………………………………………
Rencana melahirkan di : PMB / PUSKESMAS / Rumah Sakit
Latar belakang sosial budaya : Ibu mempercayai adat………………………………...
Ibu memiliki kebiasaan pijat perut / minum jamu : Tidak / Iya

B. DATA OBJEKTIF
1. Pemeriksaan Umum
Keadaan umum : Baik/ Cukup Baik/ Buruk
Kesadaran : Compomentis/ Apatis / Delirium / Somnolen / Soporou / Koma
Postur Tubuh : Tegak/ Bungkuk
Sikap tubuh : Lordosis/ Skoliosis / Kifosis
Cara berjalan : Normal/ Tidak
TTV : Tekanan Darah : ........... mmHg Suhu : .......... oC
Nadi : ........... x/menit Pernapasan : .......... x/menit
 BB : ......Kg
TB : ........ cm
LILA : ........ cm
IMT : ........

2. Pemeriksaan Fisik
a. Kepala
.................................................................................................................................
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b. Muka
.................................................................................................................................
.................................................................................................................................
c. Mata
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d. Hidung
.................................................................................................................................
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e. Telinga
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f. Mulut
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g. Leher
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h. Dada
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i. Axila
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j. Payudara
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k. Abdomen
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TFU Mc Donald = ………………………………………………………………...
Leopold I : ………………………………………………………………………
………………………………………………………………………
Leopold II : Pada perut bagian kanan :…………………………………………….
………………………………………………………………………
Pada perut bagian kiri : ……………………………………………...
………………………………………………………………………
 Leopold III : ……………………………………………………………………….
………………………………………………………………………
Leopold IV : ……………………………………………………………………….
………………………………………………………………………
TBJ : ………………………………………………………………………..
Auskultasi DJJ : …………………………………………………………………..
Frekuensi : …………………………………………………………………..
l. Genetalia
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m. Anus
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n. Ekstremitas
1) Atas : : ………………………………………………………………………
……………………………………………………………………….
2) Bawah : ………………………………………………………………………
……………………………………………………………………….
3. Pemeriksaan Panggul
Distansia spinarum : .......... cm
Distansia kristarum : ......... cm
Konjungata eksternal : ......... cm
Lingkar panggul : ......... cm

4. Pemeriksaan Penunjang
Tgl : ................................... Tempat : ..............................................
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C. ANALISA DATA
Tanggal : ............................................. Jam : ……………………….
1. Diagnosa Kebidanan
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2. Masalah
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 3. Kebutuhan
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D. PENATALAKSANAAN
Tanggal : ............................................. Jam : ……………………….

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