.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
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 datang
......................................................................................................................................................
......................................................................................................................................................
2.
Keluhan utama
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3.
Riwayat
menstruasi
Menarche : ….. tahun Siklus : ….. hari
Lama : ….. hari Teratur : ………..……………
Sifat darah : ……………..…….. Keluhan : …………..…………
4.
Riwayat
perkawinan
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 |
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6.
Riwayat kontrasepsi yang digunakan
|
No. |
Jenis Kontrasepsi |
Pasang |
Lepas |
||||||
|
Tgl |
Oleh |
Tempat |
Keluhan |
Tgl. |
Oleh |
Tempat |
Alasan |
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7.
Riwayat kehamilan sekarang
a. HPM : .......................... 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 24
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
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)
................................................................................................................................................
................................................................................................................................................
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
10.
Kebiasaan yang mengganggu kesehatan
(merokok, minum jamu, minuman beralkohol)
.....................................................................................................................................................
.....................................................................................................................................................
11.
Psikososiospiritual (persiapan menghadapi proses persalinan)
...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
12. Pengetahuan ibu (tentang kehamilan, persalinan dan laktasi)
...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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 :
......................................................................................................................
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) :
..............................................................................................
..............................................................................................
..............................................................................................
Pemeriksaan
dalam Tanggal
................., Jam ........... WIB
Indikasi :
......................................................................................................................
Tujuan :
......................................................................................................................
Hasil :
......................................................................................................................
......................................................................................................................
......................................................................................................................
3. Pemeriksaan
Penunjang Tanggal : ..............., Jam ...........
WIB
...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
4. Data
Penunjang
...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
II. INTERPRETASI
DATA
A. Diagnosa Kebidanan
B. Masalah
C. Kebutuhan
III. IDENTIFIKASI DIAGNOSA/MASALAH
POTENSIAL
IV. ANTISIPASI TINDAKAN SEGERA
V. PERENCANAAN
VI. PELAKSANAAN Tanggal :
....................., Jam : ...............WIB, Oleh
:.........................
VII.EVALUASI Tanggal :
....................., Jam : ...............WIB
PERKEMBANGAN
Tanggal : ........................
Jam : ............... WIB
I. DATA SUBYEKTIF
II. DATA OBYEKTIF
III. ASSESMENT
A. Diagnosa Kebidanan
B. Masalah
C. Kebutuhan
IV. PLANING
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 |
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