FAKULTAS KESEHATAN
A. PENGKAJIAN
I. BIODATA
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III. RIWAYAT KESEHATAN
A. RIWAYAT KEHAMILAN
1) Jumlah kunjungan ke bidan/dokter : ....................................................................................
2) Pendidikan kesehatan yang didapatkan : ............................................................................
3) Kenaikan BB selama hamil : ................................................................................................
4) Penyakit yang diderita ibu saat hamil : .................................................................................
5) Keluhan saat hamil: .............................................................................................................
6) Imunisasi selama hamil: .......................................................................................................
7) Obat-obatan/vitamin yang dikonsumsi: .................................................................................
8) Riwayat minum jamu: ...........................................................................................................
9) Riwayat dipijat (Bhs Jawa: dioyok): ......................................................................................
B. RIWAYAT KELAHIRAN
1) Lama persalinan: ..................................................................................................................
2) Komplikasi persalinan: .........................................................................................................
3) Cara persalinan: ........................................................................................
4) Tempat melahirkan: .............................................................................................................
5) Penolong persalinan: ...........................................................................................................
6) Usia gestasi: ........................................................................................................................
7) Kondisi air ketuban: ..............................................................................................................
Mengetahui, ...............................,.......................................
Pembimbing klinik
Mahasiswa
(.......................................................) (............................................................)
NIM.
B. DIAGNOSA KEPERAWATAN
NAMA & TANDA
NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN PERAWAT
C. RENCANA TINDAKAN KEPERAWATAN
DIAGNOSA TANGGAL
NO
KEPERAWATAN
S: S: S:
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O: O: O:
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A: A: A:
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P: P: P:
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Mengetahui,
Pembimbing Klinik Mahasiswa
(.......................................................) (............................................................)
NIM.