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No. Register : ………………………….
Masuk RS tanggal / jam :
………………………….
Dirawat diruang :
………………………….
I. PENGKAJIAN
Tanggal :
...................., Jam : ...............WIB, Oleh :
...........................…......
1.
Identitas
Ibu Suami
Nama :
................................................... ...................................................
Umur :
................................................... ...................................................
Agama : ................................................... ...................................................
Suku/Bangsa :
................................................... ...................................................
Pendidikan :
................................................... ...................................................
Pekerjaan :
................................................... ...................................................
Alamat :
................................................... ...................................................
No. Telp :
................................................... ...................................................
- Alasan datang
......................................................................................................................................................
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- Keluhan utama
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- Riwayat menstruasi
Menarche :
….. tahun Siklus : ….. hari
Lama :
….. hari Teratur : ………..……………
Sifat darah :
……………..…….. Keluhan : …………..…………
- Riwayat perkawinan
Status pernikahan : ...................... Menikah ke : ….....................
Lama
: …… tahun Usia
menikah pertama kali :……. tahun
- Riwayat obstetrik : G..... P..... A..... Ah......
Hamil ke-
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Persalinan
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Nifas
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Tanggal
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Umur
khamiln
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Jns prsalinan
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Penolong
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komplikasi
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JK
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BB Lahir
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Laktasi
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Komplikasi
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- Riwayat kontrasepsi yang digunakan
No.
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Jenis
Kontrasepsi
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Pasang
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Lepas
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Tgl
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Oleh
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Tempat
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Keluhan
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Tgl.
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Oleh
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Tempat
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Alasan
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- Riwayat kehamilan sekarang
a. HPM T:
.......................... 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)
................................................................................................................................................................................................................................................................................................
- 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
……………………………………………………………………………………………….
- Pola Pemenuhan kebutuhan sehari-hari
a. Pola
nutrisi
Makan
Frekuensi :
.......x/hari, Porsi :
..............................................
Jenis : .......................................... Pantangan :
..............................................
Keluhan :
..........................................
Minum
Frekuensi : .......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, Keluhan
: ..............................................
Tidur malam
Lama :
..... jam/hari, Keluhan :
..............................................
d. Personal
hygiene
Mandi :
..... x/hari Ganti
pakaian :
...... x/hari
Gosok gigi :
...... x/hari Mencuci
rambut : ...... x/minggu
e. Pola
seksualitas
Frekuensi : ..... x/minggu Keluhan : ..............................................
f. Pola
aktivitas (terkait kegiatan fisik, olah raga)
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g. Pola pemenuhan kebutuhan terakhir
Makan, tanggal .........................,
Jam ............ WIB, Jenis.....................................................
Minum,
tanggal ........................., Jam ............ WIB, Jenis.…………………………………
BAK, tanggal………… ……...., Jam …….... WIB
BAB, tanggal ………..……….., Jam …….... WIB
Istirahat/tidur,
tanggal…………………., lama…….jam
11.
Kebiasaan yang mengganggu kesehatan
(merokok, minum jamu, minuman beralkohol minum
rendaman akar fatima )
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12.
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)
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12. Pengetahuan ibu (persalinan dan
laktasi)
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13. Lingkungan
yang berpengaruh (sekitar rumah dan hewan peliharaan)
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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
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Hidung : ......................................................................................................................
Mulut :
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Telinga :
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Leher :
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Dada : ......................................................................................................................
Payudara :
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Abdomen :
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Palpasi Leopold
Leopold I : ………..........................................................................................................
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Leopold II :
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Leopold III : ......................................................................................................................
Leopold IV :
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Penurunan kepala per5an : ……
Palpasi supra pubic :
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Osborn test :
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TFU
menurut Mc. Donald : ....... cm, TBJ :
..........................................................
His :
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Auskultasi
DJJ :
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Ekstremitas
atas :
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Ekstremitas
bawah :
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Genetalia
luar :
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Anus :
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Pemeriksaan
panggul (bila perlu) :
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Pemeriksaan
dalam I Tanggal
................., Jam ........... WIB
Indikasi : ......................................................................................................................
Tujuan :
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Hasil : ......................................................................................................................
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3. Pemeriksaan Penunjang Tanggal : ..............., Jam ...........
WIB
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I. INTERPRETASI DATA
A. Diagnosa Kebidanan
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B. Masalah
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C. Kebutuhan
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III. IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL
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IV. ANTISIPASI
TINDAKAN SEGERA
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V. PERENCANAAN
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VI. PELAKSANAAN Tanggal : ....................., Jam : ...............WIB,
Oleh :......................... ......................................................................................................................................................
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VII.EVALUASI Tanggal :
....................., Jam : ...............WIB.
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PERKEMBANGAN
Tanggal :
........................
Jam : ...............
WIB
I. DATA SUBYEKTIF
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II. DATA OBYEKTIF
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III. ASSESMENT
A. Diagnosa Kebidanan
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B. Masalah
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C. Kebutuhan
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IV. PLANING
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LEMBAR OBSERVASI
No. Reg. : .................. Nama pasien :...................... Umur :…..
th Nama suami : ..........................
G... P... A... Ah... Alamat : .................................................
Masuk tgl/jam:................./..........WIB
Ketuban pecah sejak jam :........WIB Mules sejak jam : …… WIB
TGL
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JAM
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DJJ
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HIS
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NADI
(x/menit)
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SUHU
(ºC)
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LAIN-LAIN
(TD, Ketuban, PD, Px Penunjang)
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Frek.
(x/10 menit)
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Durasi
(detik)
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Kekuatan
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