Contoh proposal usaha nature mom and baby care

FORMAT ANC SOAP

ASUHAN KEBIDANAN KOMPREHENSIF DAN BERKESINAMBUNGAN

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Kunjungan ANC 1

 

No. Register                                                    : ……………………………………………….

Masuk RS/PKM/BPM tanggal /pukul            : ……………………………………………….

Dirawat diruang                                              : ……………………………………………….

 

PENGKAJIAN DATA Tanggal/Pukul :…………….. WIB, Oleh : ...........................….......

A.  DATA SUBYEKTIF

Biodata                   Ibu                                                       Suami

Nama                      : ...................................................       ...................................................

Umur                      : ...................................................       ...................................................

Agama                    : ...................................................       ...................................................

Suku/Bangsa          : ...................................................       ...................................................

Pendidikan             : ...................................................       ...................................................

Pekerjaan                : ...................................................       ...................................................

Alamat                    : ...................................................       ...................................................

No. Telp                 : ...................................................       ...................................................

 

1.      Alasan datang

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2.       Keluhan utama

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3.         Riwayat menstruasi

Menarche         :...................................            Siklus              : .....................................

Lama               :...................................            Teratur             :......................................

Sifat darah       :...................................            Keluhan           : .....................................

 

4.         Riwayat perkawinan

Status pernikahan        :.......................            Menikah ke     : .....................................

Lama                          :.......................            Usia menikah pertama kali :...............                        

5.         Riwayat obstetrik : G ...... P ..... A.....Ah ......

Hamil ke-	Persalinan							Nifas
	Tanggal	Umur khamiln	Jns prsalinan	Penolong	komplikasi	JK	BB Lahir	Laktasi	Komplikasi

 

6.         Riwayat kontrasepsi yang digunakan

No.	Jenis Kontrasepsi	Pasang				Lepas
		Tgl	Oleh	Tempat	Keluhan	Tgl.	Oleh	Tempat	Alasan

 

7.         Riwayat kehamilan sekarang

a. HPM : ............................................             HPL :..........................................

b. ANC pertama umur kehamilan : ................ minggu

c. Kunjungan ANC

Trimester I 

Frekuensi    : ............... Kali, Tempat : .................................. Oleh :...........................

Keluhan      : .................................................................................................................

Komplikasi : .................................................................................................................

Terapi          : .................................................................................................................

Trimester II

Frekuensi    : ............... Kali, Tempat : .................................. Oleh :...........................

Keluhan      : .................................................................................................................

Komplikasi : .................................................................................................................

Terapi          : .................................................................................................................

Trimester III

Frekuensi    : ............... Kali, Tempat : .................................. Oleh :...........................

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)

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8.       Riwayat kesehatan

a. Penyakit yang pernah /sedang diderita (menular, menurun dan menahun)

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b. Penyakit yang pernah /sedang diderita keluarga (menular, menurun dan menahun)

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c. Riwayat keturunan kembar

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d. Riwayat operasi

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e. Riwayat alergi obat

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9.        Pola Pemenuhan kebutuhan sehari-hari

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         : ………………………          ………………………

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)

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10.    Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)

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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.

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12.     Pengetahuan ibu (tentang kehamilan, persalinan dan nifas)

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13.    Lingkungan yang berpengaruh (sekitar rumah dan hewan peliharaan)

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B.   DATA OBYEKTIF

1.    Pemeriksaan umum

Keadaan umum         : ..............................................................................               

Kesadaran                 : ..............................................................................   

Status emosional       : ..............................................................................   

Tanda vital sign :

                                    Tekanan darah : ............mmHg           Nadi                : ................ x/menit

        Pernapasan      : ............x/menit          Suhu                : ................⁰C

        Berat badan     : ............kg                  Tinggi badan   : ............... cm

        Kenaikan BB  : ............kg                  BB sebelum hamil :.......... kg

 

2.   Pemeriksaan fisik

Kepala           : .................................................................................................................

Wajah            : .................................................................................................................

Mata              : .................................................................................................................

Hidung          : .................................................................................................................

Mulut                        : .................................................................................................................

Telinga          : .................................................................................................................

Leher             : .................................................................................................................

Dada             : .................................................................................................................

Payudara       : .................................................................................................................

Abdomen      : .................................................................................................................

Palpasi Leopold

Leopold I      : .................................................................................................................

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Leopold II    : .................................................................................................................

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Leopold III   : .................................................................................................................

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Leopold IV   : .................................................................................................................

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Osborn test   : .................................................................................................................

Pemeriksaan Mc. Donald      : TFU ..............cm,      TBJ      : ...........................gram

Auskultasi DJJ                      : ...............x/menit, reguler/ireguler

Ekstremitas atas        : ......................................................................................................

Ekstremitas bawah     : ......................................................................................................

Genetalia luar            : ......................................................................................................

Pemeriksaan panggul (bila perlu)      : ..............................................................................

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3.    Pemeriksaan Penunjang                    Tanggal : ....................., Jam .........................WIB

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4.   Data Penunjang

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C.  ASSESMENT

       Diagnosa kebidanan

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       Data Dasar :

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D.  PLANNING                    Tanggal :……………………, Pukul : ………………WIB

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Lembar Implementasi

Hari/Tanggal : …………………………….

No.	Jam	Pelaksanaan	Paraf Nama

 

    Pembimbing Institusi                           Pembimbing Lahan                               Mahasiswa

 

 

 

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