Format Askeb ANC
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No. Register :
…………………………....................................
Masuk RS/PKM/BPM Tanggal/Pukul : ………………………………….......………......
Dirawat di ruang : .............................................................................
I.
PENGKAJIAN
DATA, Tanggal/Pukul : ...............................
Oleh : ...................................
A. Biodata Ibu Suami
1.
Nama :
.................................................... ......................................................
2.
Umur : .................................................... ......................................................
3.
Agama : .................................................... ......................................................
4.
Suku/bangsa : .................................................... ......................................................
5.
Pendidikan : .................................................... ......................................................
6.
Pekerjaan : .................................................... ......................................................
7.
Alamat : .................................................... ......................................................
B. Data Subjektif
1.
Alasan
datang/dirawat
..................................................................................................................................................................................................................................................................................
2.
Keluhan
utama
..................................................................................................................................................................................................................................................................................
3.
Riwayat
menstruasi
Menarche : ................................. Siklus : ........................................
Lama : ................................. Teratur : ........................................
Sifat
darah : ................................. Keluhan :
........................................
4.
Riwayat
perkawinan
Status
perkawinan : ..................... Menikah
ke : ..................................
Lama : ..................... Usia menikah pertama kali : ..........
5.
Riwayat
obstetrik : G...... P....A....Ah....
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Hamil ke
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Persalinan
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Nifas
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Tanggal
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Umur kehamilan
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Jenis persalinan
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Penolong
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Komplikasi
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JK
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BB lahir
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Laktasi
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Komplikasi
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6.
Riwayat
kontrasepsi yang digunakan
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No
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Jenis kontrasepsi
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Pasang
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Lepas
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tanggal
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oleh
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tempat
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keluhan
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tanggal
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oleh
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Tempat
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Alasan
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7.
Riwayat
Kehamilan Sekarang
a. HPM
: ..........................
b. ANC
pertama umur kehamilan : ..........
minggu
c. Kunjungan
ANC
Trimester I
Frekuensi :
..........kali
Keluhan :
.................................................................................................................
Komplikasi:................................................................................................................
Terapi :
.................................................................................................................
Trimester
II
Frekuensi :
..........kali
Keluhan :
.................................................................................................................
Komplikasi:................................................................................................................
Terapi :
.................................................................................................................
Trimester III
Frekuensi : ..........kali
Keluhan : .................................................................................................................
Komplikasi:................................................................................................................
Terapi :
.................................................................................................................
d. Imunisasi
TT : ............kali
TT 1 : tanggal...............................
TT 2 : tanggal...............................
TT 3 : tanggal...............................
TT 4 : tanggal...............................
TT 5 : tanggal...............................
e. Pergerakan
janin selama 24 jam(dalam sehari)
........................................................................................................................................................................................................................................................................
8.
Riwayat
kesehatan
a. Penyakit yang pernah/sedang diderita
(menular, menurun dan menahun)
........................................................................................................................................................................................................................................................................ ....................................................................................................................................
....................................................................................................................................
b. Penyakit yang pernah/sedang diderita
keluarga (menular, menurun dan menahun)
........................................................................................................................................................................................................................................................................ ....................................................................................................................................
....................................................................................................................................
c. Riwayat keturunan kembar
............................................................................................................................................................................................................................................................................................................................................................................................................
d. Riwayat operasi
........................................................................................................................................................................................................................................................................ ....................................................................................................................................
e. Riwayat alergi obat
............................................................................................................................................................................................................................................................................................................................................................................................................
9.
Pola
pemenuhan kebutuhan
Sebelum hamil Saat hamil
a. Nutrisi
Makan
Frekuensi :
........ x/hari ...........
x/hari
Jenis :
.............................. ................................
Porsi :
.............................. ................................
Pantangan :
.............................. ................................
Keluhan :
.............................. ................................
Minum
Frekuensi :
........ x/hari ...........
x/hari
Jenis :
.............................. ................................
Porsi :
.............................. ................................
Pantangan :
.............................. ................................
Keluhan :
.............................. ................................
b. Eliminasi
BAB
Frekuensi :
........ x/hari ...........
x/hari
Warna :
.............................. ...............................
Konsistensi :
.............................. ...............................
Keluhan :
.............................. ...............................
BAK
Frekuensi :
........ x/hari ...........
x/hari
Warna :
.............................. ...............................
Konsistensi :
.............................. ...............................
Keluhan :
.............................. ...............................
c. Istirahat
Tidur siang
Lama : ........ jam/hari ...........
jam/hari
Keluhan : ................................ ................................
Tidur malam
Lama : ........ jam/hari ........... jam/hari
Keluhan : ................................ ................................
d. Personal Hygiene
Mandi : ......
x/hari ......
x/hari
Ganti pakaian : ...... x/hari ...... x/hari
Gosok gigi : ...... x/hari ...... x/hari
Keramas :
...... x/minggu ......
x/minggu
e. Pola seksualitas
Frekuensi :
...... x/minggu ...... x/minggu
Keluhan : ................................ ................................
f. Pola aktivitas (terkait kegiatan fisik,
olah raga)
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10. Kebiasaan yang mengganggu kesehatan
(merokok, minum jamu, minuman beralkohol)
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11. Data psikososial, spiritual dan ekonomi
(penerimaan ibu/suami/keluarga terhadap kelahiran, dukungan keluarga, hubungan
dengan suami/keluarga/tetangga, perawatan bayi, kegiatan ibadah, kegiatan
sosial, keadaan ekonomi keluarga
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12. Pengetahuan ibu (tentang kehamilan,
persalinan, nifas)
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
13. Lingkungan yang berpengaruh (sekitar rumah
dan hewan peliharaan)
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. Data Objektif
1.
Pemeriksaan
umum
Keadaan umum : .......................................................................
Kesadaran :
.......................................................................
Status emosional :
.......................................................................
Tanda vital :
Tekanan darah : .............mmHg Nadi :
...........x/menit
Pernafasan :
............x/menit Suhu : ...........x/menit
BB :
............kg TB : ...........cm
2.
Pemeriksaan
Fisik
Kepala :
.................................................................................................................
Wajah : .................................................................................................................
Mata :
.................................................................................................................
Hidung : .................................................................................................................
Mulut :
.................................................................................................................
Telinga : .................................................................................................................
Leher :
.................................................................................................................
Dada :
.................................................................................................................
Payudara :
.................................................................................................................
Abdomen :
.................................................................................................................
Palpasi
Leopold
I :
.................................................................................................................
.................................................................................................................
Leopold
II :
.................................................................................................................
.................................................................................................................
Leopold
III :
.................................................................................................................
.................................................................................................................
Leopold
IV :
.................................................................................................................
.................................................................................................................
Osborn
test :
.................................................................................................................
Pemeriksaan
Mc. Donald
TFU : ...........cm TBJ :..................................................................
Auskultasi
Djj : ...........x/menit
Ekstremitas Atas :
.....................................................................................................
Ekstremitas
Bawah :
.....................................................................................................
Genetalia luar :
.....................................................................................................
Pemeriksaan
panggul: ....................................................................................................
(bila perlu)
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
3.
Pemeriksaan
penunjang Tgl : ....................... Pukul : .........WIB
..................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................
4.
Data
penunjang
..................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................
.........................................................................................................................................
II.
INTERPRETASI
DATA
A. Diagnosa kebidanan
..........................................................................................................................................................................................................................................................................
Data Dasar:
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................
B. Masalah
..........................................................................................................................................................................................................................................................................
Data Dasar:
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III.
IDENTIFIKASI
DAN ANTISIPASI DIAGNOSA
POTENSIAL
..........................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.
TINDAKAN
SEGERA
A. Mandiri
............................................................................................................................................................................................................................................................................
B.
Kolaborasi
............................................................................................................................................................................................................................................................................
C.
Merujuk
............................................................................................................................................................................................................................................................................
V.
PERENCANAAN Tanggal : …………………. ……. Pukul : ……….....WIB
............................……………………………………………………………………….…………………..…………………………………………………………………….......…………………………………………………………………………………………….…………………………………………………………………………………………….…………………………………………………………………………………………….…………………………………………………………………………………………….………........................…......................................................................................................................................................................................................................................................
VI.
PELAKSANAAN Tanggal: .......................................... Pukul : ................WIB
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................................................................
VII. EVALUASI Tanggal : ........................................... Pukul : .......... .....WIB
.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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