PENGKAJIAN
I. IDENTITAS
Nama ibu
Nama suami
:
Umur
Umur
Pendidikan
Pendidikan :
Agama
Agama
Pekerjaan
Status perkawinan
Alamat
:
Pekerjaan
Tanggal pengkajian
Diagnosa medis
2. DATA SUBJEKTIF
a. keluhan utama
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b. riwayat Kesehatan Sekarang
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c. Riwayat Kehamilan Sekarang
ANC(Ante Natal Care) :.........................teratur/tidak.................................................
Diperiksa
: ..............................................................................................
Imunisasi
:.............................................................................................
....................siklus......................lamanya..........teratur/tidak...........
Jumlah :......................Warna:..................dismenorhe:...................................
HPHT
e. Riwayat obsteri
G.............................P.................................A........................................................
.
ANAK
KE
JENKEL
UMUR
RIWAYAT PERSALINAN
LANIR
USIA
HAMIL
PENOLONG
PENYULIT
BBL
KET
penyakit
alergi
merokok dan obat-obatan
g. Riwayat penyakit Keluarga
.......................................................................................................................................
.......................................................................................................................................
h. Keadaan Psikososial
Rencana melahirkan
...........................................................................................................................
Rencana menyusui
...........................................................................................................................
i. Seksual
...........................................................................................................................
.
Perubahan istirahat, tidur,dan cara mengatasinya
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Jumlah jam istirahat/ tidur perhari
...........................................................................................................................
. Pola eleminasi
Buang Air Besar
:...............x/hari
Riwayat Penyakit Ginjal
Penggunaan diuretik
:...................X/hari
:...................x/hari
:......................
:......................
3. PEMERIKSAAN FISIK
a. secara umum
Tanda- tanda vital
Tekanan darah
:......................................mm/Hg
Suhu
:......................................C
Nadi
:......................................x/ menit
Pernapasan
:......................................x/ menit
Berat badan sekarang
:......................................Kg
Berat Badan sebelum lahir :..........................Kg
LILA
:......................................Cm
b. Secara head To Toe
Kepala
Rambut
Muka
Mata/ konjungtiva
:...........................
:...........................
:...........................
Hidung
:...........................
Mulut
:...........................
Leher
Inspeksi
: Gondok
:..........................................................
Palpasi
: Masa
:..........................................................
Auskultasi
: Bruit Aorta
:..........................................................
Dada
Payudara membersar :.......................
Puting susu
:.......................
Kebersihan
:.......................
Simetris
:.......................
Abdomen
Inspeksi
Straiae Gravidarum :....................................
Hiperpigmentasi
:....................................
Auskultasi
DJJ
:.....................................
Bising usus
:.....................................
Palpasi
Leopold I
:.....................................
Leopold II
:.....................................
Leopold III
:.....................................
Leopold IV
:.....................................
Perkusi
:.....................................
Ekstremitas
Kekuatan otot :.....................................
Reflek Patela
:.....................................
Reflek Babinski
:.....................................
Edema
:.....................................
Chubb
:.....................................
c. pemeriksaan laboratorium
HB
:...........................Gol. Darah
:...............................................Rh+/:........................................................................................................
Urine
..
USG
:.............................................................................................
.............
d. data penunjang therapy
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ANALISA DATA
DATA
PENYEBAB
MASALAH
DO
...................................
.
DS
...................................
RENCANA INTERVENSI
NO
DIAGNOSA
TUJUAN
KRITERIA
HASIL
INTERVENSI
RASIONALISASI
NO.
DIAGNOSA
HARI/TANGGAL
TINDAKAN
EVALUASI