.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
No. Register : .........................................................................
Tanggal RS/PKM/BPM Tanggal /Pukul :
.........................................................................
Tempat : .........................................................................
I.
PENGKAJIAN DATA Tanggal / Pukul:................................... Oleh:....................... ..
A. Biodata
Ibu Suami
1.
Nama :............................................ ...................................................
2.
Umur :............................................ ...................................................
3.
Agama : ........................................... ...................................................
4.
Suku/Bangsa :............................................ ...................................................
5.
Pendidikan :............................................ ...................................................
6.
Pekerjaan : ........................................... ...................................................
7.
Alamat : ........................................... ...................................................
B. Data Subjektif
1.
Alasan datang /
dirawat
..............................................................................................................................................................................................................................................................................
2.
Keluhan Utama
..............................................................................................................................................................................................................................................................................
3.
Riwayat Menstruasi
Menarche :........................................ Siklus :..........................
Lama :….................................... Teratur :..........................
Sifat Darah :........................................ Keluhan :..........................
4.
Riwayat Perkawinan
Status pernikahan :........................... Menikah
ke :.........................
Lama :........................... Usia menikah
pertama kali :......
5.
Riwayat
Obstetrik : P...A...Ah....
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Hamil
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Persalinan
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Nifas
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Ke
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Tanggal
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Umur kehamilan
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Jenis Persalinan
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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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6.
Riwayat
kontrasepsi yang digunakan
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No
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Jenis
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Pasang
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Lepas
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Kontrasepsi
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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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Keluhan
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Ibu
mengatakan belum pernah menggunakan alat kontrasepsi
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7.
Riwayat
Kehamilan sekarang
a. HPHT :................................ HPL :..........................
b. ANC pertama umur
kehamilan : ...............................
c. Kunjungan ANC
Trimester I
Frekuensi :..............kali
Keluhan :..............
Komplikasi :..............
Terapi :..............
Trimester II
Frekuensi :..............kali
Keluhan :..............
Komplikasi :..............
Terapi :..............
Trimester III
Frekuensi :..............kali
Keluhan :..............
Komplikasi :..............
Terapi :..............
d. Imunisasi TT
TT 1 :...................
TT 2 :...................
TT 3
:...................
TT 4
:...................
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
Sebelum Hamil Setelah Hamil
a.
Pola
Nutrisi
-
Makan
Frekuensi :................. x/hari ...........................
Porsi :................. ...........................
Jenis :................. ...........................
Pantangan :................. ...........................
Keluhan :................. ...........................
-
Minum
Frekuensi :................. ...........................
Porsi :................. ...........................
Jenis :................. ...........................
Pantangan :................. ...........................
Keluhan :................. ...........................
b.
Eliminasi
-
BAB
Frekuensi : ................. ............................
Konsistensi : ................. ............................
Warna :
................. ............................
Keluhan :
................. ............................
BAK
Frekuensi : ................. ............................
Konsistensi : ................. ............................
Warna : ................. ............................
Keluhan : ................. ............................
c.
Istirahat
Tidur siang Tidur malam
Lama :
................. ............................
Keluhan :
................. ............................
d.Personal hygiene
Mandi : ................. ............................
Ganti pakaian : ................. ............................
Gosok gigi : ................. ............................
Keramas : ................. ............................
e.Pola
seksualitas
Frekuensi : ................. ............................
Keluhan : ................. ............................
f. Pola aktifitas ( terkait kegiatan fisik,
olah raga )
.....................................................................................................................................................................................................................................................................................................................................................................
10.
Kebiasaan
yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11.
Psikososiospiritual
(persiapan menghadapi persalinan)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12.
Pengetahuan
ibu (tentang kehamilan, persalinan, dan nifas)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
13.
Lingkungan
yang berpengaruh (sekitar rumah dan hewan peliharaan)
..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
C. DATA
OBYEKTIF
1.
Pemeriksaan
Umum
Keadaan Umum :.........................................................................
Kesadaran :.........................................................................
Status Emosional :.........................................................................
Vital Sign
Tekanan Darah :..............mmHg Nadi :............x/menit
Pernafasan : .............x/menit Suhu :............
°C
Berat badan : .............kg Tinggi badan :............ cm
2. Pemeriksaan
Fisik
Kepala :..............................................................................................................
Wajah :..............................................................................................................
Mata :..............................................................................................................
Hidung :..............................................................................................................
Mulut :..............................................................................................................
Telinga :..............................................................................................................
Leher :..............................................................................................................
Dada :..............................................................................................................
Payudara :..............................................................................................................
Abdomen :..............................................................................................................
Palpasi Leopold
Leopold I :..................................................................................................
Leopold II :..................................................................................................
Leopold III :..................................................................................................
Leopold IV :..................................................................................................
Supra pubic :..................................................................................................
Osborn test :..................................................................................................
TFU menurut Mc.
Donald
TFU:...................cm TBJ:........................................
Auskultasi DJJ
DJJ:.....................x/menit
Ekstremitas atas :..................................................................................................
Ekstremitas bawah :..................................................................................................
Genetalia luar :..................................................................................................
Pemeriksaan Dalam :..................................................................................................
...................................................................................................................................................................................................................................................................................................
3. Pemeriksaan Penunjang Tgl :..........................
Pukul:..............WIB
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Data Penunjang
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
II. INTERPRETASI DATA
A.
Diagnosa
Kebidanan
............................................................................................................................................................................................................................................................................
Data dasar :
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
B.
Masalah
............................................................................................................................................................................................................................................................................
Data dasar :
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III. IDENTIFIKASI
DIAGNOSA/MASALAH POTENSIAL
.....................................................................................................................................................................................................................................................................................................................................................................................................................
IV. TINDAKAN SEGERA
A.
Mandiri
............................................................................................................................................................................................................................................................................
B.
Kolaborasi
............................................................................................................................................................................................................................................................................
C.
Merujuk
............................................................................................................................................................................................................................................................................
V. PERENCANAAN Tanggal :..............................
Pukul : ..................WIB
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VI. PELAKSANAAN Tanggal :..............................
Pukul : ..................WIB
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
VII. EVALUASI Tanggal :.............................. Pukul : ..................WIB
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PERKEMBANGAN
KALA
I.
DATA
SUBYEKTIF, Tanggal :...................., jam :............................ WIB
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
II. DATA
OBYEKTIF, Tanggal :...................
, jam :............................ WIB
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III. ASESSMENT
1. Diagnosa
kebidanan
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Diagnosa
masalah
......................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
IV.
PENATALAKSANAAN, Tanggal
:................... , jam :............................ WIB
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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
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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.
(x10 menit )
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Durasi
( detik )
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Kekuatan
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