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14 January 2013

CONTOH MAKALAH ASUHAN KEBIDANAN




MAKALAH ASUHAN KEBIDANAN PADA NY.”T” CALON AKSEPTOR KB IUD JENIS CU T 380 A
.
TINJAUAN KASUS MAKALAH ASUHAN KEBIDANAN.
A. Pengkajian
Tgl pengkajian:02 juni 2007
1. Data Subyektif
a. Biodata
Istri Suami
Nama : Ny.T : Tn.S
Umur : 37 tahun : 39 tahun
Agama : Islam : Islam
Pendidikan : SMP : SMA
Pekerjaan : Wiraswasta : PNS
Alamat : Ngariboyo : Ngariboyo
Status Marital : 1 kali kawin lam 21 th : 1 kali kawin lam 21 th
b. Keluhan utama
Ibu datang ke klinik KB untuk pasang IUD
c. Riwayat Kesehatan
1) Riwayat kesehatan yang lalu
Ibu tidak pernah menderita penyakit nyeri tekan perut bawah/nyeri serfiks,kencing
terasa panas,pengeluaran pus atau mukus pervaginam (Gonorrhoea,Syphilis),
penyakit tekanan darah tinggi .
2) Riwayat kesehatan keluarga
Dalam keluarga tidak ada yang mederita penyakit dengan kelainan pembentukan
darah,DM,kanker atau paru-paru serta riwayat alergi pada logam.
3) Riwayat kesehatan sekarang
Saat dikaji ibu mengatakan tidak sedang menderita sakit kencing manis.Sakit perut
bagian bawah/nyeri tekan, pusing-pusing,anyang-anyang,panas dingin (demam).
Gemetar atau keluar keringat dingin saat beraktifitas.
d. Riwayat obstetri
1) Haid
Menarche umur 12 tahun ,siklus haid teratur 28 hari,tidak perna nyeri perut saat
haid maupun keputihan yang berlebihan shg menimbulkan gatal dan bau.
2) Riwayat kehamilan,persalinan dan nifas
- Selama kehamilan ibu teratur ke bidan,tidak mengalami gangguan/penyakit.
- Anak I,usia kehamilan 9 bln,lahir spontan di bidan,BB:3000 gr.
- Anak II usia kehamilan 9 bln,lahir spontan di bidan,BB:3400 gr,hidup tidak ada
kelainan sekarang umur 4 bulan masa nifas sehat tidak ada penyakit.
3) Riwayat KB
- Setelah kelahiran anak I ibu menggunakan KB suntik selam 3 tahun.
- Setelah kelahiran anak ke II ibu menggunakan KB IUD,krn dulu waktu ikut KB
suntuk tdk pernah mens dan BB tambah gemuk.
e. Pada kebiasan sehari-hari
1) Nutrisi
Sebelum ikut KB dan sesudah ikut KB tidak ada perubahan makan tetap 3 kl sehari
dan ibu tidak berpantang terhadap makanan.Minum 8-10 gls air putih dan teh.
2) Istirahat
Sebelum ikut KB dan sesudah ikut KB tidak ada perubahan,ibu biasa tidur siang 1,5-
2 jam,tdr mlm 8-10 jam,tidak ada gangguan kadang timbul rasa nyeri atau sakit ping
gang pada haid pertama setelah pemasangan IUD,tetapi tidak sampai menggangu pola
istirahat ibu.
3) Aktifitas
- Sebelum ikut KB
Ibu terbiasa melakukan sendiri pekerjaan rumah tangganya.
- Seudah ikut KB
Ibu sedikit membatasi aktifitas yang dirasakan berat oleh ibu tapi ibu tetp melaku
kan pekerjaan rumah tangga seperti biasanya.
4) Personal hygiene
- Sebelum ikut KB
Ibu mandi 2 kl/hr,gosok gigi 2kl/hr,keramas 3kl/hr,ganti baju 1kl/hr dan ganti cela
na dalam 2kl/hr selalu cebok setelah BAK/BAB.
- Sesudah ikut KB
Tidak ada perubahan sama dengansebelum ikut KB,hanya ibu sering ganti celana
dalam karena hari-hari pertama setelah pemasangan IUD flek-flek darah sedikit
warna hitam.
f. Pola sexual
Selama pemakaian alat kontraseosi IUD ibu mengatakn suaminya bisa menerima serta
mendukung,frekwensi senggama 1-3 kl/mg,keluhan nyeri dalam melakukan hubungan
sexual oleh pihak suami tidak begitu dipermasalahkan.
g. Latar belakang
Ibu ingin milih pasang IUD karena menurut ibu jenis KB ini sudah memesyarakat dan su
dah banyak pasangan yg memkai alat kontrasepsi ini.Klien mendapatkan persetujuan da
ri suami untuk pemakaian KB ini dan tidak bertentangan dengan adat dan budaya jawa
yang dianut oleh ibu.
2.Data Obyektif
a. Keadaan umum :Baik
b. Kesadaran : Composmentis
c. TTV
Tensi:120/80mmHg Rr:20 kl/mnt
Nadi : 80 kl/mnt Suhu : 36 drjt
BB : 56 kg TB : 155 cm
d. Pemeriksaan fisik
- Kepala : rambut bersih,warna hitam,tidak rontok,penyebaran merata.
- Mata : conjungtifa merah muda,sklera putih
- Hidung : bersih,simetris,tidak ada polip,tidak ada sekret,penciuman baik.
- Leher : Tidak ada pembengkakan kelenjar tiroid,vena jugularis dan kelenjar limfe.
- Dada : Pernafasan teratur,tidak ad ronchi,tidak terdapat hiperpiogmentasi areola.
- Abdomen: tidak ada pembesaran uterus,tidak teraba massa/tumor,tdk ada nyeri te
kan pada perut bawah,tidak ad pembesran hepar.
- Genetalia
Inspeculo : Cervic tidak dijumpai pus atau mukus yang berkebihan,tidak ada perdara
han,tidak ada oedem dan varices pd vagina.
Bimanual : Tanda-tanda infeksi tidak dijumpai,seperti nyeri tekan daerah adnexa.
- Ekstremitas
Tidak ada varices ataupun oedem pada kaki,kuku tidak pucat,tidak terdapat flambing
finger.
e. Pemeriksaan laboratorium
Tidak dilakukan.
3. Diagnosa kebidanan
P20002 37 tahun,ibu calon akseptor KB IUD jenis CU T380A, anak terkecil usia 7 th de
ngan sedikit keputihan,keadaan umum baik,tidak ada kontra indikasi.
B. Perencanaan
P20002 37 th,ibu calon akseptor KB IUD Cu T380A,anak terkecil usia 7 th dengan sedikit ke
putihan keadaan umum baik,tidak ada kontra indikasi,
Tujuan : Ibu mantap menjadi akseptor IUD
Kriteria hasil : Efek samping IUD seminimal mungkin.
Intervensi:
1. Kaji oengetahuan ibu tentang efek samping IUD.
2. Lakukan pendekatan dengan teknik komunikasi terapeutik denagn bersikap simpatik ser
ta menunjukkun perhatian pada klien.
3. Persiapan klien dengan memberi tahu tentang langkah-langkah klien yang akan dilakukan.
4. Kaji pengetahuan ibu tentang efek samping IUD.
5. Persiapan peralatan yg dibutuhkan dengan prinsip septik dan antiseptik.
6. Atur pasien dengan posisi litothomi.
7. Lakukan pemeriksaan sesuai standart pelayanan dengan secara sistematif.
8. Beritahu klien tentang hasil dari pemeriksaan.
9. Diskusikan dengan klien tentang hasil pemeriksaan.
10. Memantapkan klien dengan KB IUD yg dipilihnya.
11. Beri penjelasan ulang tentang efek samping IUD yg mungkin timbul selam 3 bulan perta
ma dan cara penanggulangannya.
12. Jadwalkan klien untuk kontrol ulang 1 minggu kemudian.
13. jadwalkan untuk pemeriksaan pap smear.
C. Pelaksanaan
Tgl : 02 juni 2007 jam 14.30 WIB
Diagnosa : P20002 umur 37 th,keadaan umum ibu baik,tidak adakontra indikasi pemasang
an.
d. Evaluasi
Tgl : 02 juni 2007 jam 17.30 WIB
S : Ibu mengatakan lega setelah dilakukn pemasangan KB IUD misal tentang bermacam-
macam efek samping yg mungkin terjadi.
O : – TTV : T :120/80 mmHg
N : 82 kl/mnt
Rr : 18 kl/mnt
S : 36 drjt
- IUD terpasang
- Ibu mantap menjadi peserta IUD baru
- Keadaan umum baik
A : Ibu menjadi peserta KB IUD baru,dengan pemasangan tanpa komplikasi.
P : Evaluasi saat kontrol berikutnya mengenai efek samping dan komplikasi IUD.


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