NORMAL ANC DOCUMENT (ASUHAN KEBIDANAN IBU HAMIL NORMAL)
MIDWIFERY CARE NORMAL PREGNANT WOMEN
IN NY. D AGES 25 YEARS G1P0A0Ah0 32
WEEKS GESTATION
PUBLIC HOSPITALS MUTIARA HUSADA CENTRAL
LAMPUNG
Assessment
Date/Time :
2 January 2015/ 15:00 WIB
MR Numbers :
14/767
Ward Room : Delivery Room
Assessment by :
Evilia Nur Savitri
A.
Subjective
Data
1.
Identity
Mother
|
Father
|
||
Name
|
Ny. A
|
Name
|
Mr. S
|
Age
|
25 th
|
Age
|
26 TH
|
Religion
|
Islam
|
Religion
|
Islam
|
Tribes
|
Java / Indonesia
|
Tribes
|
Java / Indonesia
|
Education
|
Senior High School
|
Education
|
Senior High School
|
Work
|
Housewife
|
Work
|
Entrepreneur
|
Address
|
Beji,Godean,Sleman
|
Address
|
Beji,Godean,Sleman
|
2.
Reason
Coming
Mom said want to checkup
3.
Main
Complaint
Mom said feel mild
headache and swollen feet.
4.
History
of Marriage
a.
|
Marital Status
|
: Legitimate
|
b.
|
Age Marriage
|
: 24 years old
|
c.
|
To Marry
|
: First
|
d.
|
Old Married
|
: 1 year
|
5.
Medical
history
a.
Past
Medical History
1.
Mom
said never suffer from infectious diseases such as tuberculosis, hepatitis,
measles, HV / AIDS
2.
The
mother said he had never suffered from a hereditary disease such as asthma,
heart disease, diabetes, hypertension
b.
Health
History Now
1.
Mom
says not suffering from infectious diseases such as TB, Hepatitis, measles, HIV
/ AIDS
2.
Mom
says not suffering from hereditary diseases such as asthma, heart disease, diabetes,
hypertension
3.
Mother
said has never been hospitalized or surgery
c.
Family
Health History
Mother said the
family of the mother or her husband never be or have been suffering from
cancer, heart disease, hypertension, diabetes mellitus, kidney disease, mental
illness, congenital abnormalities, twin pregnancy, tuberculosis, epilepsy, and
allergies based on the examination conducted by doctorsHistory of Obstetrics
Gynecology
a.
Menstrual
History
Menarche : 12 years old
Cycles : 28 days
Long : 7 days
Amount : 3-4 times change the bandage,
spots on day 1-2, fresh red on days 4-7. and
back brown on days 5-7
Complaint : No
The first day of
the last menstrual period: 20 June 2014
b.
History
of Pregnancy, Childbirth and Postpartum Ago
Mom said it was the
first pregnancy
c.
Pregnancy
History Now
Pregnant To
|
: 1
|
Age Pregnancy
|
: 32 Weeks
|
Due date
|
: 27 March 2015
|
Delivery Plan
|
: The Midwife
|
Blood donors
|
: Sister (Nava)
|
Transport
|
: Car
|
Cost
|
: Labor savings
|
6.
History
KB
Mother said she had
never used KB.
7.
Dialy
Custom Pattern
Custom Pattern
|
Before Pregnancy
|
During Pregnancy
|
Complaint
|
a.
Nutrition
Eat and drink
|
Eating 3 meals / day, rice, side dishes, vegetables.
Drink 8 glasses of water, sweet tea
|
Eating 3-4 times / day, rice, side dishes, vegetables,
a little snack. Drink 8 glasses of water, sweet tea, and milk
|
No problem
|
b.
Elimination
urination
|
2-3 times, dense, brownish
|
1 time, a bit soft, tawny
6-7 times,
|
No problem
|
defecate
|
7-8 times, lot, clear color
|
much, sometimes slightly yellow color clear
|
|
c.
Activity
|
Doing housework
|
Doing housework as usual, but reducing the heavy work
|
No problem
|
d.
personal
hygiene
|
Shower 2 times / day, brush your teeth two times, three
times a week to wash, change clothes 2 times
|
Shower 2 times / day, brush your teeth two times, three
times a week to wash, change clothes 2-3 times
|
No problem
|
e.
Break
|
Occasional nap, sleep 7-8 hours a night
|
Naps 1-2 hours of sleep a night for 7-8 hours
|
No problem
|
f.
sexual
patterns
|
3-4 times a week
|
1-2 times in a week
|
No problem
|
8.
Data Psychosocial,
Cultural and Spiritual
a.
Psychosocial : Mom said this pregnancy was planned and
eagerly anticipated
b.
Cultural : Mom said that decision to the messenger
carried by deliberation
c.
Spititual : Mother said about following ritual
prayers five times, Recictation every friday
9.
Knowledge
Data Client
Mom said not so familiar with the pregnancy because the
first time
10. Environment
Neighborhood : Clean and tidy, far from the crowds
Living together : Husband
Type of dwelling : permanent building
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