TINJAUAN KASUS

I. PENGKAJIAN
Tempat :
Tanggal : Jam : WIB
A. Data Subyektif
1. Biodata
Nama istri : .............................

Umur : .............................

Agama : .............................

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

Pendidikan : .............................

Pekerjaan : .............................

Penghasilan : .............................

Umur kawin : .............................

Kawin ke : .............................

Lama kawin : .............................

Alamat : .............................

Nama suami : .............................

Umur : .............................

Agama : .............................

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

Pendidikan : .............................

Pekerjaan : .............................

Penghasilan : .............................

Umur kawin : .............................

Kawin kawin : .............................

Lama kawin : .............................

Alamat : .............................

2. Keluhan utama
......................................................................................................................................................
......................................................................................................................................................
3. Riwayar Kesehatan Sekarang
......................................................................................................................................................
 ......................................................................................................................................................
......................................................................................................................................................
4. Riwayat Kesehatan yang Lalu
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
5. Riwayat Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
6. Riwayat Kebidanan
a. Riwayat Haid
Menarche : ........................................................................................................
Siklus : ........................................................................................................
Lama : ........................................................................................................
Jumlah : ........................................................................................................
Warna : ........................................................................................................
Keluhan : ........................................................................................................
Konsistensi : ........................................................................................................
Flour Albus : ........................................................................................................
Kapan : ........................................................................................................
b. Riwayat kehamilan sekarang
Hamil ke : .........................
HPHT :..........................
UK :..........................
ANC : TM I : ......x bidan/ dokter
Keluhan : ............................................................
Terapi : ............................................................
Penyuluhan : ............................................................
...................................................................................
...................................................................................
TM II : .......x bidan/ dokter
Keluhan : ............................................................
Terapi : ............................................................
Penyuluhan : ............................................................
...................................................................................
...................................................................................
 TM III : .......x bidan/ dokter
Keluhan : ............................................................
Terapi : ............................................................
Penyuluhan : ............................................................
...................................................................................
...................................................................................
TT : ....................................................................................................................
Gerakan janin : ....................................................................................................................
7. Pola Kebiasaan Sehari- hari
a. Nutrisi
Sebelum hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
Selama hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
b.Eleminasi
Sebelum hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
Selama hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
c. Istirahat/tidur
Sebelum hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
Selama hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
d. Personal hygiene
Sebelum hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
Selama hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
e. Aktivitas
 Sebelum hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................
Selama hamil :...................................................................................................................
....................................................................................................................
....................................................................................................................

f. Seksual
Sebelum hamil :...................................................................................................................
Selama hami :...................................................................................................................
....................................................................................................................
....................................................................................................................
5. Keadaan Psikososial
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
6. Keadaan Sosial Budaya
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
B. Data Objektif
Keadaan umum : .............................
Kesadaran : .............................
Poster tubuh : .............................
Cara berjalan : .............................
Tinggi Badan : .............................
BB sebelum hamil : .............................
BB sekarang : .............................
Kenaikan BB : .............................
LILA : .............................
TTV : TD : ............................. S : .....................
N : ............................. RR : .....................
a. Pemeriksaan fisik
1) Inspeksi
a) Kepala : .......................................................................................................
........................................................................................................
b) Muka : .......................................................................................................
........................................................................................................
 c) Mata : .......................................................................................................
........................................................................................................
........................................................................................................
d) Hidung : .......................................................................................................
........................................................................................................
........................................................................................................
........................................................................................................
e) Mulut & gigi : .......................................................................................................
........................................................................................................
........................................................................................................
f) Telinga : .......................................................................................................
........................................................................................................
........................................................................................................
g) Leher : .......................................................................................................
........................................................................................................
h) Axilla : .......................................................................................................
........................................................................................................
i) Mammae : .......................................................................................................
........................................................................................................
j) Abdomen : .......................................................................................................
........................................................................................................
........................................................................................................
k) Genetalia : .......................................................................................................
........................................................................................................
........................................................................................................
l) Anus : .......................................................................................................
m) Ekstremitas Atas: ................................................................................................. :
........................................................................................................
........................................................................................................
n) Ekstremitas Bawah: .............................................................................................
........................................................................................................
........................................................................................................
2) Palpasi
a) Leher : .......................................................................................................
........................................................................................................
........................................................................................................
b) Axilla : ......................................................................................................
........................................................................................................
c) Mammae : .......................................................................................................
........................................................................................................
 d) Abdomen :
Leopold I : .....................................................................................................
........................................................................................................
........................................................................................................
Leopold II : ....................................................................................................
....................................................................................................
....................................................................................................
Leopold III : ....................................................................................................
......................................................................................................
......................................................................................................
Leopold IV : ....................................................................................................
......................................................................................................
......................................................................................................
TFU MC Donald : ....................................................................................................
TBJ : ....................................................................................................
e). Genetalia : .....................................................................................................
......................................................................................................
......................................................................................................
f). Ektremitas Atas : ......................................................................................................
.....................................................................................................
g). Ektremitas Bawah: ....................................................................................................
.....................................................................................................
3) Auskultasi
a. Dada : ...............................................................................................................
b. Abdomen : ............................................................................................................
c. DJJ : ..............................................................................................................
..............................................................................................................
..............................................................................................................
4) Perkusi
Reflek patella : ..............................................................................................................
b. Pemeriksaan penunjang
Hb : .....
Protein urin : .....
Glukosa urin : ......
c. Pemeriksaan panggul luar
Distansia spinarum : .............
Distansia cristarum : .............
Konjungata eksterna : .............
Lingkar panggul : .............

II. IDENTIFIKASI DIAGNOSA/ MASALAH KEBUTUHAN

Tanggal : Jam : WIB

..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
 ..............................................................................................................................................................
..............................................................................................................................................................

III. ANTISIPASI MASALAH POTENSIAL

-
IV. IDENTIFIKASI KEBUTUHAN SEGERA
-
V. INTERVENSI
Tanggal : Jam: WIB

..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
....................................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................

VI. IMPLEMENTASI
Tanggal : Jam : WIB
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
 ..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
VII. EVALUASI
Tanggal : Jam : WIB

..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
Pembimbing Akedemik Pembimbing Praktek