Asuhan Kebidanan Pada Ibu Bersalin [PDF]

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Contoh Format Pendokumentasian Manajemen Kebidanan Pada Ibu Bersalin ASUHAN KEBIDANAN PADA IBU BERSALIN ....................................................................................................................................................... ....................................................................................................................................................... NO. REGISTER MASUK RS TANGGAL, JAM DI RAWAT DI RUANG Biodata Nama Umur Agama Suku/bangsa Pendidikan Alamat No. Telepon/HP



: : : : : : :



: ........................................................................................... : ........................................................................................... : ...........................................................................................



Ibu .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. ..................................................



Suami .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. ..................................................



DATA SUBJEKTIF 1.



Alasan masuk kamar bersalin ..............................................................................................................................................



2.



Keluhan utama .............................................................................................................................................. ..............................................................................................................................................



3.



Tanda-tanda persalinan



a.



Kontraksi uterus sejak tanggal ........................................................... Jam ......................... Frekuensi : ........................ kali dalam 10 menit Durasi : ........................ detik Kekuatan : Kuat / sedang /lemah Lokasi ketidaknyamanan di .................................................................................................



b.



Pengeluaran per vagiman Lendir darah : ya / tidak Air ketuban : ya / tidak, banyaknya ................... cc, warna ............................ Darah : ya / tidak, banyaknya ................... cc, warna ............................



4.



Riwayat sebelum masuk ruang bersalin



5.



Riwayat kehamilan sekarang HPM .......................................... HPML .......................................... Manarche umur .................... tahun, siklus .................... hari, lama .................... hari, Banyaknya .................... cc ANC teratur / tidak, frekuensi .................... kali, di ................................................ Keluhan / komplikasi selama kehamilan .................................................................................................................................... .................................................................................................................................... Riwayat merokok / minum-minuman keras / minuman jamu .................................. Imunisasi TT 1 : ya / tidak, tanggal .......................................................................... Imunisasi TT 2 : ya / tidak, tanggal ..........................................................................



6.



Pergerakan janin dalam 24 jam terakhir .............................................. kali



7.



Riwayat kehamilan, persalinan dan nifas yang lalu. Persalinan



Hamil



8.



Umur



Jenis



Lahir



Kehamilan



Persalinan



Penolong



Nifas Komplikasi Ibu Bayi



Jenis



BB



Kelamin



Lahir



Laktasi



Komplikasi



Riwayat kontrasepsi yang digunakan



No



9.



Tgl



Jenis Kontrasepsi



Tanggal



Oleh



Mulai Memakai Tempat Keluhan



Tanggal



Berhenti/Ganti Cara Oleh Tempat Komplikasi



Riwayat kesehatan a. Penyakit yang pernah / sedang di derita ........................................................................................................................... ........................................................................................................................... b.



Penyakit yang pernah / sedang di derita keluarga ........................................................................................................................... ...........................................................................................................................



a.



Riwayat keturunan kembar ........................................................................................................................... ...........................................................................................................................



10.



Makan terakhir tanggal ........................ jam ........................ jenis .......................... Minum terakhir tanggal ........................ jam ........................ jenis .........................



11.



Buang air besar terakhir tanggal ..................................... jam .................................



12.



Buang air kecil terakhir tanggal ..................................... jam .................................



13.



Istirahat / tidur dalam 1 hari terakhir ……………….. jam



14.



Keadaan Psiko Sosio Spritual / kesiapan menghadapi proses persalinan a. Pengetahuan tentang tanda-tanda persalinan dan proses persalinan ........................................................................................................................... ........................................................................................................................... b.



Persiapan persalinan yang telah dilakukan (pendamping ibu, biaya, dll) ........................................................................................................................... ...........................................................................................................................



c.



Tanggapan ibu dan Keluarga terhadap proses persalinan yang dihadapi ........................................................................................................................... ...........................................................................................................................



DATA OBJEKTIF 1.



Pemeriksaan fisik



a.



Keadaan umum ................................................. Kesadaran .....................................



b



Status emosional .......................................................................................................



c.



Tanda vital Tekanan daran Nadi Pernafasan Suhu



: : : :



................................... mmHg ................................... kali per menit ................................... kali per menit ................................... º C



TB BB



: :



................................... cm Sebelum hamil .............. kg, BB sekarang ............. kg



d.



LLA



:



................................... cm



e.



Kepala dan leher Edema wajah : ................................................................................................ Cloasma gravidarum + / Mata : ................................................................................................ Mulut : ................................................................................................ Leher : ................................................................................................



f.



Payudara Bentuk Puting susu Colostrum



g.



Abdomen Pembesaran Benjolan Bekas luka Strie gravidarum Pelapasi leopold Leopold I Leopold II Leopold III Leopold IV Obsorn test TBJ Aukultasi DJJ



: : :



................................................................................................ ................................................................................................ ................................................................................................



: : : :



................................................................................................ ................................................................................................ ................................................................................................ ................................................................................................



: : : : : : :



................................................................................................ ................................................................................................ ................................................................................................ ................................................................................................ ................................................................................................ ................................................................................................ Punctum maksimum .............................................................. Frekuensi : .................... kali per menit ( .... / .... / ... ) His : Frekuensi : .................... kali dalam 10 menit Frekuensi : .................... detik Kekuatan : kuat / sedang / lemah Palpasi supra publik : .......................................................................................... h.



Punggung



i.



Pinggang



j.



Ektremitas Kekuatan otot dan sendi Edema Varices Reflek patela Kuku



: : : : :



..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................



Genetalia luar Tanda chadwich Varices Bekas luka Kelenjer bartholini Pengeluaran



: : : : :



..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................



Anus Hemoroid



:



.....................................................................



k.



l.



:



..........................................................................................



: nyeri / tidak



2.



Pemeriksaan dalam, tanggal ............................., oleh ............................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................



3.



Pemeriksaan penunjang .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................



.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ASSEMENT 1.



Diagnosis Kebidanan .................................................................................................................................... ....................................................................................................................................



2.



Masalah .................................................................................................................................... ....................................................................................................................................



3.



Kebutuhan .................................................................................................................................... ....................................................................................................................................



4.



Diagnosis Potensial .................................................................................................................................... ....................................................................................................................................



5.



Masalah Kebidanan .................................................................................................................................... ....................................................................................................................................



6.



Kebutuhan tindakan segera berdasarkan kondisi klien a. Mandiri ........................................................................................................................... ........................................................................................................................... b.



Kalaborasi ...........................................................................................................................



c.



Merujuk ........................................................................................................................... ...........................................................................................................................



PLANNING (Termasuk Pendokumentasian Implementasi dan Evaluasi) Tanggal ........................................ jam .......................... Tanda tangan



( .................................. )