I
POLITEKNIK KESEHATAN
PALANGKARAYA
Jl. G. Obos No. 32 Palangkaraya. Telp/Fax : (0536) 21768, 35146, 37504
E-mail : poltekkes_kalteng@telkom.net
NAMA MAHASISWA
NIM
TEMPAT PRAKTEK
TANGGAL PRAKTEK
: MARIATI
: PO.62.24.2.10.101
: ...........................................................
: ...........................................................
B. ANAMNESA
Pada Tanggal
: .....................................
Pukul : ...............................
1. Kunjungan yang ke
: .................................
2. Alasan kunjungan
: ........................................................................................................
Keluhan utama
: .........................................................................................................
.........................................................................................................
.........................................................................................................
3. Riwayat psikososial
a. Kehamilan ini
( ) direncanakan
( ) diterima
( ) tidak direncanakan
( ) tidak diterima
b. Perasaaan tentang kehamilan ini : ......................................................................................
c. Emosional ibu saat pengkajian : .....................................................................................
d. Jenis kelamin yang diharapkan : ( ) laki-laki
( ) perempuan
(
) keduanya diterima
e. Status perkawinan
: Perkawinan ke ........., usia menikah ........... th dengan
suami ........... th. Lama perkawinan ......... bln/th. Status perkawinan ................................
f. Perilaku kesehatan
: ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
) suami
) keluarga (
M : meninggal
: dengan penyakit ..................
--- : tinggal serumah
) ............................
5. Riwayat Obstetri
a. Riwayat Haid
Haid pertama
Siklus/lama haid
Banyaknya
b. Riwayat kehamilan
HPHT
TP
Keluhan-keluhan
Trimester I
: ....................... tahun
: .......... /........... hari
:........ kali ganti pembalut/hari
teratur/tidak teratur
sifat darah : ..............................
dismenorhe : ..............................
( ) 10x
( ) 10x s/d 20x
( ) 20x
( ) 15 detik
( ) 15 detik
( ) ....................
: ...........................................................
7. Riwayat KB
Jenis kontrasepsi
Kapan
Lama penggunaan
Keluhan
Alasan dilepas
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
8. Riwayat kesehatan
Penyakit yang pernah atau sedang diderita
Penyakit
Jantung
Hipertensi
Hepar
Diabetes mellitus
PMS
Campak
Malaria
TBC
Lainnya
Klien
Keluarga
Keterangan
9. Riwayat kebiasaan
a. Pola makan dan minum
.......................................................................................................................................................
.......................................................................................................................................................
b. Pola eliminasi
.......................................................................................................................................................
.......................................................................................................................................................
c. Pola istirahat dan tidur
.......................................................................................................................................................
.......................................................................................................................................................
d. Personal hygiene
.......................................................................................................................................................
.......................................................................................................................................................
e. Aktivitas sehari - hari
.......................................................................................................................................................
.......................................................................................................................................................
f. Seksualitas
.......................................................................................................................................................
.......................................................................................................................................................
g. Imunisasi
TT
( ) belum ( ) sudah ......... kali tanggal : I ............................. II ...........................
C. PEMERIKSAAN FISIK
1. Tanda Vital
Tekanan Darah
: ................ mmHg
Nadi
: ................ x/menit
Pernafasan
: ................ x/menit
Suhu
: ................ oC
2. Lingkar Lengan Atas
: ............... cm
3. Tinggi Badan
: ............... cm
4. Berat badan sebelum hamil
: ............... kg
Berat badan sekarang
: ............... kg
Chadwick
: ...............................................................................................
16. Anus
Hemoroid
: ...............................................................................................
17. Ekstremitas
Tangan
: Kuku
Oedema
Kaki
: Varises
Oedema
Refleks Patella
18. Punggung
Lordosis
Kiposis
Skoliosis
Ketuk costovertebra
19. Ukuran Panggul Luar
Distansia Spinarum
Distansia Kristarum
Conjunggata eksterna
Lingkar panggul
20. Ukuran Panggul Dalam
: ...............................................................................................
: ...............................................................................................
: ...............................................................................................
: ...............................................................................................
: ( ) tidak ada
( ) ada,
kanan ( )
kiri ( )
:(
:(
:(
:(
) Ya
) Ya
) Ya
) Ya
(
(
(
(
) Tidak
) Tidak
) Tidak
) Tidak
: .............. cm
: .............. cm
: .............. cm
: .............. cm
: .............................
(normal : 25 26 cm)
(normal : 26 28 cm)
(normal : 18 19 cm)
(normal : 80 90 cm)
D. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ......................................
Pukul : .............................
a. Darah
b. Urine
Hb
: ................ gr %
Protein
: ...............................
Gol. Darah
: ................
Reduksi
: ...............................
Rhesus
: ................
2. Pemeriksaan Penunjang Lainnya
.............................................................................................................................................................
.............................................................................................................................................................
....................................., ....................................
Pembimbing Lahan Praktek
Mahasiswa
( ................................................... )
NIP.
( MARIATI)
NIM. PO.62.24.2.10.112
( .............................................. )
NIP.