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Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :
A. DATA SUBYEKTIF
1. IDENTITAS
Nama : .......................................... Nama Suami :
No Reg : ..........................................
2. KELUHAN
a. Saat MRS
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3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
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3.2 Penyakit sekarang
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3.3 Penyakit Keluarga
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Penolong:...............................................
atas indikasi....................................................................................................................................
Komplikasi:......................................................................................................................................
Plasenta ..........................................................................................................................................
tali pusat........................cm
Perenium : ...........................................................................................................................
Epidemiologi .........................................................................................................................
Perdarahan :
Kala I : ................................cc
Kala II : ................................cc
Kala IV : ................................cc
Kala II : ..........................jam.....................menit
Apgar :………………………………………
8. RIWAYAT KB
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9. RIWAYAT PERNIKAHAN
Usia....................berapa kali.................................
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2. Eliminasi
3. Istirahat & Tidur
4. Personal hygiene
5. Aktivitas
6. Pola Sexualitas
B. DATA OBJEKTIF
1. KEADAAN UMUM :
- Kesadaran :.....................................................................................................................................
- TTV :.....................................................................................................................................
- TB :.....................................................................................................................................
2. PEMERIKSAAN FISIK
Rambut :.....................................................................................................................................................................
Wajah :.....................................................................................................................................................................
Mata :.....................................................................................................................................................................
Hidung :.....................................................................................................................................................................
Mulut :.....................................................................................................................................................................
Telinga :.....................................................................................................................................................................
b. Pemeriksaan Leher
Inspeksi :.....................................................................................................................................................................
Palpasi :.....................................................................................................................................................................
- Payudara
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- Jantung
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- Paru
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Inspeksi : ....................................................................................................................................................................
e. Pemeriksaan Genetalia
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f. Pemeriksaan Ekstremitas
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g. Pemeriksaan Integumen
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3 PEMERIKSAAN PENUNJANG
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4. TERAPI
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ANALISA DATA