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Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :
A. DATA SUBYEKTIF
1. IDENTITAS
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Penghasilan : Penghasilan :
Alamat : Alamat :
No Reg :
2. KELUHAN
a. Saat MRS
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b. Saat Pengkajian (Keluhan Utama)
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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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4. RIWAYAT OBSTETRI / KEBIDANAN
4.1 Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .....................................................................
Menarche :.......................................................... Dismenorhea: .....................................................................
Lama :.......................................................... Flour Albus : .....................................................................
Banyak : ........................................................
Siklus :.........................................................
muda .....................................................................................................................................................................
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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
Kala II : ..........................jam ....................menit
Kala IV : ........................jam......................menit
Apgar :………………………………………
8. RIWAYAT KB
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RIWAYAT PERNIKAHAN
Usia....................berapa kali.................................
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10. POLA AKTIFITAS
2. Eliminasi
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 :............................................................................................................................................................
- Payudara
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- Jantung
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- Paru
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Inspeksi:............................................................................................................................................................................
Palpasi : ..................................................................................................................................................................
Auskultasi :.........................................................................................................................................................................
e. Pemeriksaan Ekstremitas
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f. Pemeriksaan Genetalia
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g. Pemeriksaan Integumen
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3. PEMERIKSAAN PENUNJANG
a. Laboratorium/USG
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b. Radiologi
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4. TERAPI
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5. ANALISA DATA