I. Pengkajian
Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
Cara masuk :
Diagnose
A. DATA SUBYEKTIF
1. Keluhan
utama : ...................................................................................................................................
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2. Riwayat menstruasi
Usia manarche :
Jumlah darah haid :
HPHT :
Keluhan saat haid :
Lama haid :
Flour albus :
TP :
Keluhan haid :
Dll..............
B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
Palpasi : TFU : .................cm, letak punggung :....................
Presentasi : ................................ penurun kepala : .....................................
TBJ : ...........................gram
Auskultasi : BJJ................x/mnt, reguler / irreguler
His/kontraksi : ......................
b. Ano genital
Inspeksi : pengeluaran pervagina......................condiloma : ada / tidak
Inspekulo : vagina (cairan/darah dan luka), portio : (licin/berdungkul,
cairan/darah, luka/lesi, apakah serviks sudah membuka atau belum), terdapat
jaringan plasenta/ bagian kecil janin.
Vaginal toucher : ............cm eff.........% ketuban(+/-) presentasi.................
denominator ....................... hodge ...............kesan panggul : normal / PSR /PSA
4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- USG : ...........................................
C. ANALISA
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D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................
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Kediri,............................
Pembimbing Praktik Mahasiswa
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NIP. NIM.
Dosen Pembimbing
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NIP.