.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
No. Register : ………………………….
Masuk RS tanggal / jam :
………………………….
Dirawat diruang :
………………………….
I. PENGKAJIAN Tanggal :
...................., Jam : ...............WIB, Oleh :
...........................…......
A. IDENTITAS
Ibu Suami
Nama :
................................................... ...................................................
Umur :
................................................... ...................................................
Agama : ................................................... ...................................................
Suku/Bangsa :
................................................... ...................................................
Pendidikan :
................................................... ...................................................
Pekerjaan :
................................................... ...................................................
Alamat :
................................................... ...................................................
No. Telp :
................................................... ...................................................
B.
DATA SUBYEKTIF
1.
Alasan kunjungan
............................................................................................................................
............................................................................................................................
2.
Keluhan utama
………………………………………………………………………………...
………………………………………………………………………………...
3.
Riwayat
menstruasi
Menarche : ….. tahun Siklus :..................hari
Lama : ….. hari Teratur :.........................
Sifat darah : ……………..…….. Keluhan : …………..…..
4.
Riwayat
pernikahan
Status pernikahan :
...................... Menikah ke : ….....................
Lama
: …… tahun Usia menikah
pertama kali :……. Tahun
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. HPHT: .......................... HPL :
........
b.ANC pertama umur kehamilan : .......... minggu
c.Kunjungan ANC
Trimester I
Frekuensi :….. x, Tempat :…….………………… Oleh ..................
Keluhan
: ..........................................................................................
Terapi :…………………………………………….......................
Trimester II
Frekuensi :….. x, Tempat :…….………………….Oleh : ................
Keluhan
:...........................................................................................
Terapi :
………………………………………..............................
Trimester
III
Frekuensi :….. x, Tempat
:…….…………………. Oleh : ….............
Keluhan :............................................................................................
Terapi : ……………………………………...................................
d. Imunisasi
TT
........................................................................................................................................................................................................................................................................
e. Pergerakan janin selama 12
jam(dalam sehari)
........................................................................................................................................................................................................................................................................
8.
Riwayat
kesehatan
a. Penyakit yang pernah /sedang diderita
(menular, menurun dan menahun)
………………………………………………………………………………..………………………………….............…………………………………....................
b. Penyakit yang pernah /sedang diderita
keluarga (menular, menurun dan menahun)
…………………………………………………………………………………..… ……………………………….............…………………………………………....
c. Riwayat
keturunan kembar
…………………………………………………………………………………….
d.
Riwayat operasi
…..………………………………………………………………………………...
e. Riwayat
alergi obat
…………………………………………................................................................
9.
Pola
pemenuhan kebutuhan sehari-hari
a.Pola nutrisi sebelum hamil saat hamil
Makan
Frekuensi :
.......x/hari ........x/hari
Porsi :
.................................. ...............................
Jenis : .................................. ...............................
Pantangan :
.................................. ...............................
Keluhan : .................................. ...............................
Minum
Frekuensi :
.......x/hari, .........x/hari
Porsi :
................................... ..............................
Jenis : ................................... ..............................
Pantangan :
................................... ..............................
Keluhan : ................................... ..............................
b.Pola
eliminasi
BAB
Frekuensi :
................................ ...............................
Konsistesi :
................................ ...............................
Warna :
................................ ...............................
Keluhan :
…............................ ...............................
BAK
Frekuensi :
................................. ..............................
Konsistesi :
................................. ..............................
Warna :
................................. ..............................
Keluhan :
…............................. ..............................
c. Pola
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)
..........................................................................................................................................
....................................................................................................................................................................................................................................................................................
..........................................................................................................................................
10.
Kebiasaan
yang mengganggu kesehatan ( merokok,minum jamu,minuman beralkohol)
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
………………………………………………………………………………………….
11.
Psikososiospiritual
( penerimaan ibu/suami/keluarga terhadap kehamilan ,dukungan sosial,perencanaan
persalinan,pemberian ASI,perawatan bayi,kegiatan ibadah,kegiatan sosial,dan
persiapan keuangan ibu dan keluarga)
………………………………………………………………………………………….
………………………………………………………………………………………….
………………………………………………………………………………………….
…………………………………………………………………………………………
12.
Pengetahuan
ibu ( tentang kehamilan,persalinan,dan laktasi)
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
13.
Lingkungan
yang berpengaruh ( sekitar rumah dan hewan peliharaan)
..........................................................................................................................................
..........................................................................................................................................
...........................................................................................................................................
..........................................................................................................................................
C. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : ....................................
Kesadaran :
....................................
Status emosional : ....................................
Tanda vital sign :
Tekanan darah : ................. mmHg Nadi : ................ x/menit
Pernapasan : ................. x/menit Suhu : ................ x/menit
Berat badan : ................. kg Tinggi badan : ................ cm
2. Pemeriksaan fisik
Kepala :
......................................................................................................................
Rambut :
......................................................................................................................
Muka :
......................................................................................................................
Mata : ................., sklera
..............................., konjungtiva
....................................
Hidung : ......................................................................................................................
Mulut :
......................................................................................................................
Telinga : ......................................................................................................................
Leher :
......................................................................................................................
Dada : ......................................................................................................................
Payudara :
......................................................................................................................
......................................................................................................................
Abdomen :
......................................................................................................................
......................................................................................................................
Palpasi Leopold
Leopold I : ………..........................................................................................................
……………………………………………………………………………..
Leopold II :
......................................................................................................................
……………………………………………………………………………..
Leopold III : ......................................................................................................................
Leopold IV :
......................................................................................................................
……………………………………………………………………………..
Osborn test :
..............................................................................................
TFU
menurut Mc. Donald : ....... cm, TBJ :
..........................................................
Auskultasi
DJJ : ..............................................................................................
Ekstremitas
atas :
......................................................................................................................
Ekstremitas
bawah : ......................................................................................................................
Genetalia
luar :
......................................................................................................................
Anus : ......................................................................................................................
Pemeriksaan
panggul (bila perlu) :
..............................................................................................
..............................................................................................
..............................................................................................
3. Pemeriksaan Penunjang Tanggal : ..............., Jam ...........
WIB
...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
I. INTERPRETASI DATA
A. Diagnosa Kebidanan
....................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
B. Masalah
......................................................................................................................................................
......................................................................................................................................................
...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
C. Kebutuhan8
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
III. IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
IV. ANTISIPASI
TINDAKAN SEGERA
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
V. PERENCANAAN
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
VI. PELAKSANAAN Tanggal : ....................., Jam : ...............WIB,
Oleh :......................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
VII.EVALUASI Tanggal :
....................., Jam : ...............WIB.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Tidak ada komentar:
Posting Komentar