Selasa, 30 April 2013

FORMAT INC



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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                      : ...................................................       ...................................................
  1. Alasan datang
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  1. Keluhan utama
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  1. Riwayat menstruasi
Menarche             : ….. tahun                                          Siklus              : ….. hari 
Lama                    : ….. hari                                             Teratur             : ………..……………
Sifat darah           : ……………..……..                          Keluhan           : …………..…………

  1. Riwayat perkawinan
Status pernikahan : ......................                       Menikah ke     : ….....................
Lama                    : …… tahun                           Usia menikah pertama kali :……. tahun                                
  1. Riwayat obstetrik : G..... P..... A..... Ah......
Hamil ke-
Persalinan
Nifas
Tanggal
Umur khamiln
Jns prsalinan
Penolong
komplikasi
JK
BB Lahir
Laktasi
Komplikasi



















































  1. Riwayat kontrasepsi yang digunakan
No.
Jenis Kontrasepsi
Pasang
Lepas
Tgl
Oleh
Tempat
Keluhan
Tgl.
Oleh
Tempat
Alasan































  1. 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
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e.  Pergerakan janin selama 12 jam(dalam sehari)
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  1. 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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  1. 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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13Lingkungan 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 ....................................
       Hidung                 : ......................................................................................................................
       Mulut                    : ......................................................................................................................
       Telinga                  : ......................................................................................................................
       Leher                    : ......................................................................................................................
       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   : ......................................................................................................................
            Penurunan kepala per5an         : ……
            Palpasi supra pubic                  : ..............................................................................................
            Osborn test                              : ..............................................................................................
            TFU menurut Mc. Donald       : ....... cm,        TBJ      : ..........................................................
            His                                           : ..............................................................................................
            Auskultasi DJJ                         : ..............................................................................................   
       Ekstremitas atas   : ......................................................................................................................
       Ekstremitas bawah            : ......................................................................................................................
       Genetalia luar       : ......................................................................................................................
       Anus                     : ......................................................................................................................
       Pemeriksaan panggul (bila perlu) : ..............................................................................................
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       Pemeriksaan dalam I                                                        Tanggal ................., Jam ........... WIB
            Indikasi            : ......................................................................................................................
            Tujuan              : ......................................................................................................................
            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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Text Box: Pembimbing Akademik



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Text Box: Pembimbing Lapangan



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Text Box: Praktikan



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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
JAM
DJJ
HIS
NADI
(x/menit)
SUHU
(ºC)
LAIN-LAIN
(TD, Ketuban, PD, Px Penunjang)
Frek.
(x/10 menit)
Durasi
(detik)
Kekuatan





































































































































































































































































Pembimbing Akademik



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