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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 :
Diagnosa Medis :
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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
Kala IV : ........................jam......................menit
Keadaan Bayi Baru Lahir
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
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...
- TTV
:............................................................................................................................................
- TB
:...........................................................................................................................................
:............................................................................................................................................
2. PEMERIKSAAN FISIK
- Rambut
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- Wajah
:...........................................................................................................................................................
- Mata
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- Hidung
:..........................................................................................................................................................
- Mulut
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- Telinga
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b. Pemeriksaan Leher
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- Payudara
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- Jantung
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- Paru
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Inspeksi
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Palpasi :
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Auskultasi :
:.........................................................................................................................................................................
e. Pemeriksaan Ekstremitas
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f. Pemeriksaan Genetalia
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g. Pemeriksaan Integumen
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1. PEMERIKSAAN PENUNJANG
a. Laboratorium/USG
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b. Radiologi
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2. TERAPI
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3. ANALISA DATA
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5. INTERVENSI
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NO TANGGAL/JAM IMPLEMENTASI
NO TANGGAL/JAM IMPLEMENTASI
7. EVALUASI
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NO TANGGAL/JAM EVALUASI
NO TANGGAL/JAM EVALUASI