PENGKAJIAN
I. Identitas
Identitas Ibu Identitas Suami
Nama (Inisial) : ____________ Nama (Inisial) : ____________
Umur : ____________ Umur : ____________
Agama : ____________ Agama : ____________
Suku Bangsa : ____________ Suku Bangsa : ____________
Status Perkawinan : ____________ Status Perkawinan : ____________
Pekerjaan : ____________ Pekerjaan : ____________
Pendidikan terakhir : ____________ Pendidikan terakhir : ____________
Alamat rumah : _______________________________________________________________________________
2. Riwayat Keperawatan
a. Keluhan Utama
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c. Riwayat Obstetri
1) Kehamilan, persalinan, dan nifas yang lalu
2) Riwayat Mestruasi
Menarche : ___________________________
Siklus : ___________________________
Lama : ___________________________
Jumlah : ___________________________
Disminorea : ___________________________
3. Pemeriksaan Fisik
a. Keadaan Umum : ____________________
b. Kesadaran : ____________________
c. Tanda-tanda vital
Tekanan Darah : _____ mmHg Pernapasan : ______ x/menit
Nadi : _____ x/menit Suhu : _____0C
d. Head to toe
1) Kepala dan Rambut
Rontok : _______________________________________________________________________
Warna rambut : _______________________________________________________________________
Distribusi : _______________________________________________________________________
Kulit kepala : _______________________________________________________________________
Nyeri tekan : _______________________________________________________________________
2) Wajah
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3) Mata
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4) Hidung
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5) Mulut
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6) Telinga
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7) Leher
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8) Axilla
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9) Dada/Thorax
a) Sistem Pernapasan
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b) Sistem Kardiovaskuler
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c) Payudara
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10)Abdomen
a) Inspeksi
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b) Palpasi
Leopold I : _____________________________________________________________________
Leopold II : _____________________________________________________________________
Leopold III : _____________________________________________________________________
Leopold IV : _____________________________________________________________________
c) Auskultasi (DJJ)
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11) Genetalia dan anus
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2) Nutrisi
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3) Eliminasi :
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5) Proteksi
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6) Sense
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7) Cairan dan elektrolit
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8) Fungsi neurologi :
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9) Fungsi endokrin :
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d. Interdependensi Mode
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2. Pengkajian tahap 2
a. Stimulus fokal
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b. Stimulus kontekstual
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c. Stimulus residual
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