Askeb Kb Suntik
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YAYASAN HAJI SOEHEILY QARI SEKOLAH TINGGI ILMU KESEHATAN (STIKES) MERANGIN PRODI D III KEBIDANAN Jln.Bangko–Kerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten Merangin [email protected] MANAJEMEN ASUHAN KEBIDANAN PADA IBU AKSEPTOR PADA IBU KB SUNTIK Tempat praktek :............................. Nama Mahasiswa :............................ Nomor MR :............................. No.Absen :............................. Masuk RS.H/Tgl/Jam :............................. Keterampilan ke :............................. 1. Pengkajian data 1. Identitas ISTRI SUAMI Nama :................... ..................... Umur :.................... ..................... Agama :.................... ..................... Suku/Bangsa :.................... ..................... Pendidikan :.................... ..................... Pekerjaan :.................... ..................... Alamat :...................... ....................... 2. Anamnesia (Data Subjektif) a............................Keluhan Utama : ...................................................... b. Riwayat Perkawinan Kawin....kali,Kawin Pertama Kali Umur.....Tahun, Dengan suami sekarang sudah .........tahun. c. Riwayat Haid Menarche Umur ....tahun, Cyclus..... kali :, Teratur/Tidak, Sakit/Tidak, Lamanya ...... hari, Sifat
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Transcript of Askeb Kb Suntik
YAYASAN HAJI SOEHEILY QARISEKOLAH TINGGI ILMU KESEHATAN (STIKES) MERANGIN
PRODI D III KEBIDANANJln.Bangko–Kerinci Km.6 Kungkai, Kecamatan Bangko Kabupaten
Merangin [email protected]
MANAJEMEN ASUHAN KEBIDANAN PADA IBU AKSEPTOR PADA IBU KB SUNTIK
Tempat praktek :............................. Nama Mahasiswa :............................
Nomor MR :............................. No.Absen :.............................
Masuk RS.H/Tgl/Jam :............................. Keterampilan ke :.............................
1. Pengkajian data1. Identitas
ISTRI SUAMINama :................................................. ...................................................
Umur :.................................................. ...................................................
Agama :.................................................. ...................................................
Suku/Bangsa :.................................................. ...................................................
Pendidikan :.................................................. ...................................................
Pekerjaan :.................................................. ...................................................
Alamat :....................................................... ........................................................
2. Anamnesia (Data Subjektif)
a.Keluhan Utama :...........................................................................................
b.Riwayat Perkawinan
Kawin....kali,Kawin Pertama Kali Umur.....Tahun, Dengan suami sekarang
sudah .........tahun.
c.Riwayat Haid
Menarche Umur ....tahun, Cyclus..... kali :, Teratur/Tidak, Sakit/Tidak,
Lamanya ...... hari, Sifat Darah : Encer/Beku, Bau..........Flour Albus...............
d.Riwayat Obstetri :
NO
Usia Kehamilan
Proses Persalinan/Penolong
BAYIKet
BBL JKHidup/Mati
Nifas pendarahan
e. Riwayat KB
n
o
Alat/ cara Mulai pakai Berhenti/Ganti Cara Alasan
Tgl Bln Th Oleh Di Tgl Bln Th Oleh Di
f. Riwayat Kesehatan
Penyakit yang pernah diderita :.....................................................
Penyakit yang diderita sekarang :......................................................
Pengobatan yang diberikan :...................................................
g. Pola pemenuhan Kebutuhan Sehari-hari :......................................................
1) Nutrisi
-Pola makan perhari :.....................................................
-Jenis makanan yang dikonsumsi :......................................................
2) Eliminasi
a. BAK
Frekuensi :...........................................................................
Warna :...........................................................................
Keluhan :...........................................................................
b. BAB
Frekuensi :............................................................................
Sifat :............................................................................
Warna :............................................................................
Keluhan :...........................................................................
3) Istirahat
Tidur Siang :...........................................................................
4) Aktifitas
Di dalam rumah :...........................................................................................
Di luar rumah :..........................................................................................
5) Personal Hygiene
Kebiasaan membersihkan alat kelamin :................................................
Kebiasaan mengganti pakaian dalam :................................................
Jenis bahan pakaian yang dipakai :.................................................
6) Seksual :.................................................
Frekuensi :............................................................................................................
Keluhan :............................................................................................................
.........................................................................................................................
h. Kebiasaan yang berhubungan dengan kesehatan
Obat –obatan /Jamu :.......................................................................................
Merokok :.......................................................................................
Dll :.......................................................................................
i. Data Psikososial, Spiritual
Tanggapan ibu terhadap penggunaan alat kontrasepsi :.......................................
j. Pengetahuan ibu tentang Alat Kontrasepsi :.......................................
3.Data Obyektif
a. Pemeriksaan Umum
Keadaan Umum : ........................................................................................
TTV: TD : ........................................................................................
.........................................................................................................................
S : ........................................................................................
.........................................................................................................................
Nadi : ........................................................................................
.........................................................................................................................
Pernafasan : .......................................................................................
.........................................................................................................................
BB :.........................................................................................
TB : ........................................................................................
.........................................................................................................................
b. Pemeriksaan Khusus (Obstetri)
1. Insfeksi
Kepala : ................................................................................
.........................................................................................................................
Muka : .................................................................................
.........................................................................................................................
Leher : .................................................................................
.........................................................................................................................
Dada : ..................................................................................
.........................................................................................................................
Jantung : .................................................................................
.........................................................................................................................
Paru :..................................................................................
.........................................................................................................................
Payudara :...................................................................................
.........................................................................................................................
Perut : ..................................................................................
.........................................................................................................................
Punggung dan pinggang : ..................................................................................
.........................................................................................................................
Vulva/genitalia :..................................................................................
.........................................................................................................................
Anus : .................................................................................
Kaki : ..................................................................................
Periksa Dalam (Pada Akseptor IUD )
Gerakan Serviks bebas/ tidak
Tanda-tanda kehamilan
Tanda-tanda tumor/infeksi
Posisi Uterus
In Spekulo ( kalau perlu ) :
