TINJAUAN KASUS

Tanggal : ......................

Tempat : .............................

Jam : ........................WIB
LANGKAH I (PENGKAJIAN DATA)
A. DATA SUBYEKTIF
1. Identitas

Penanggung jawab/Suami

Nama

: ..........................

Nama

: .......................

Umur

: ..........................

Umur

: .......................

Agama

: ..........................

Agama

: .......................

Suku/Bangsa : ..........................

Suku/Bangsa

: .......................

Pendidikan

: ..........................

Pendidikan

: .......................

Pekerjaan

: ..........................

Pekerjaan

: .......................

Alamat

: ..........................

Alamat

: .......................

2. Status Perkawinan
a. Isteri

b.

Suami

- Perkawinan ke-

: ..............

- Perkawinan ke-

: ..............

- Umur kawin

: ..............

- Umur kawin

: ..............

- Lama kawin

: ..............

- Lama kawin

: ..............

3. Alasan Kunjungan
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4. Riwayat Kebidanan
a.

Haid

- Menarche

: .................................

- Siklus/lama

: .................................

- Banyaknya

: .................................

- Warna/bau

: .................................

- Dismenorrohoe

: .................................

- Flour Albus

: .................................

- HPHT

: ............................ TP : ........................

- UK

: .................................

b.
Perk

Riwayat Kehamilan, Persalinan dan Nifas yang lalu

Kehamilan

Persalinan

Ke

Jns

Anak

Nifas

awin
an

UK

ke-

c.

Penol

Tm

Peny Se

pt

BBL Hid
up

Ma AS

Pen

ti

KB

Riwayat Kehamilan Sekarang

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5. Riwayat Kesehatan Yang Lalu

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6. Riwayat Kesehatan Keluarga

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7. Riwayat Psikososial
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8. Riwayat Sosial Budaya
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9. Pola Kebiasaan Sehari-hari
a. Pola nutrisi
Sebelum hamil : Makan :
Minum :
Selama hamil :

Makan :
.........................................................................
Minum :

b. Pola eliminasi
Sebelum hamil : BAB :
BAK:
.........................................................................................
.........................................................................................
Selama hamil : BAB
BAK :

c. Aktivitas
Sebelum

hamil
:
............................................................................................

Selama

hamil
:
............................................................................................

d. Pola istirahat
Sebelum hamil : Tidur siang : .......................................
Tidur malam : .....................................
Selama hamil : Tidur siang

: .......................................

Tidur malam : .......................................

e. Personal hygiene

Sebelum hamil :
..............................................................................................
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..............................................................................................

Selama hamil :
................................................................................................
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................................................................................................

f. Pola seksual
Sebelum hamil : .............................
Selama hamil : ...............................
B. DATA OBYEKTIF
1.

Pemeriksaan Fisik Umum

a. Keadaan Umum

: ..............................

- Kesadaran

: ..............................

- Postur tubuh

: ..............................

- Cara berjalan

: ..............................

- BB sebelum hamil

: ..................... kg

- BB saat ini

: ..................... kg

- Kenaikan

: ..................... kg

- TB/LILA

: ............cm/............cm

b.

TTV :
T : ........ mmHg

N : ........ x/mnt

S : ........C

RR : ..... x/mnt

2. Pemeriksaan Fisik Khusus

a. Inspeksi
Kepala :
.......................................................................................................
Muka

Mata

:
.......................................................................................................
.....................................................................................................
.....................................................................................................

Hidung :
.......................................................................................................
.....................................................................................................
Mulut

:
.......................................................................................................
.....................................................................................................

Telinga :
.......................................................................................................
.......................................................................................................
Leher

:
.......................................................................................................
.......................................................................................................

Dada

:
.......................................................................................................

Mammae :
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...................................................................................................

...................................................................................................
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Abdomen :
.....................................................................................................
...................................................................................................
Genetalia

Anus

Eksterna

:
.......................................................................................................
.......................................................................................................
.......................................................................................................

Ekstremitas
Atas

Bawah :

b. Palpasi
Kepala : .....................................................................................................
Leher

:
.......................................................................................................
.....................................................................................................

Ketiak :
.......................................................................................................
.......................................................................................................
Mammae :
.....................................................................................................

Abdomen :
...................................................................................................
...................................................................................................
...................................................................................................
...................................................................................................
LI

:
...................................................................................................
................................................................................................
................................................................................................
................................................................................................

LII

:
................................................................................................
................................................................................................
................................................................................................

LIII

:
................................................................................................

LIV

:
................................................................................................

TBJ

: ..................... gr.

Ekstremitas
Atas

:
.......................................................................................................

Bawah :
.......................................................................................................
c. Auskultasi

Dada

Abdomen : DJJ :

:
.............................. = .........x/menit

d. Perkusi

e. Pemeriksaan Ukuran Panggul Luar (UPL)

f. Kesimpulan
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LANGKAH

II

(IDENTIFIKASI

DIAGNOSA,

MASALAH

DAN

KEBUTUHAN)
Diagnose :
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............................................................................................................
DS

DO

Masalah :
Data Subyektif :
Data Obyektif :
Kebutuhan :
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LANGKAH III (ANTISIPASI MASALAH POTENSIAL)
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LANGKAH IV (IDENTIFIKASI KEBUTUHAN SEGERA)
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LANGKAH V (INTERVENSI)
Diagnose :
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............................................................................................................
Tujuan

:
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Criteria

Intervensi :
1. ..........................................................................................................................
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2. ..........................................................................................................................
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3. ..........................................................................................................................
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4. ..........................................................................................................................
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5. ..........................................................................................................................
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LANGKAH VI (IMPLEMENTASI)

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LANGKAH VII (EVALUASI)
Tanggal : ..........................

Jam : .........WIB

Diagnose :
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S :
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O :
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A :
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P :
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