SK. MENDIKNAS RI. No. 117/D/O/2009, Tanggal. 3 Agustus 2009 | DEPKES RI. Kode Institusi 61072401S, Tanggal. 7 Oktober 2009
I. PENGKAJIAN
A. IDENTITAS
Nama Ibu : Ny. L Nama Suami : Tn. A
Umur : 23 tahun Umur : 27 tahun
Agama : Islam Agama : Islam
Suku / Bangsa : WNI Suku / Bangsa : WNI
Pendidikan : SMK Pendidikan : SI
Pekerjaan : IRT Pekerjaan : PNS
Status Perkawinan : Ya/Tidak Lamanya : 3Tahun
Alamat Rumah : .............................................................................................................................................
No HP / Telp : .............................................
B. KELUHAN UTAMA
.....................................................................................................................................................................................
.....................................................................................................................................................................................
C. RIWAYAT KESEHATAN
1. Riwayat haid
a. Menarce : 12 tahun
b. Siklus : Teratur / tidak, 28 hari
c. Lamanya : 5 hari
d. Masalah : .............................................................................................................................................
e. Haid terakhir : .............................................................................................................................................
2. Riwayat anak
a. Jumlah anak yang hidup : ..............................................................................................................................
b. Jumlah anak lahir mati : ...............................................................................................................................
c. Umur anak terkecil : ..................... tahun
D. PEMERIKSAAN FISIK
1. Tinggi badan : ......................cm
2. Berat badan : ......................kg
3. Tanda-tanda vital
TD : .....................mmHg Nadi : .............................. x/menit
RR : .................X / menit Suhu : ............................. 0C
4. Kulit
a. Warna : ...............................
b. Turgor : ...............................
5. Rambut
a. Warna : .................................
b. Kebersihan : .................................
c. Lain-lain : .................................
6. Muka
a. Oedem : ..................................
b. Hiperpigmentasi : ...............................
c. Lain-lain : ..................................
7. Mata
a. Konjungtiva : ..................................
b. Sklera : ..................................
c. Lain-lain : ..................................
8. Gigi dan mulut
a. Oral hygine : .................................
b. Masalah : .................................
9. Leher
a. Kelenjar thyroid : teraba membesar / tidak
b. Vena jugularis : membesar / tidak
10. Dada
a. Bentuk : simetris / tidak
b. Auskultasi
- Paru : .................................
- Jantung : .................................
c. Buah dada
- Bentuk : simetris / tidak
- Konsistensi : lembut / keras
- Pembesaran : ya / tidak
- Teraba benjolan : ya / tidak
- Pengeluaran ASI : ya / tidak
11. Abdomen
a. Pembesaran : ya / tidak
b. Hepar : teraba / tidak
c. Pembesaran uterus : ya / tidak
d. Lain-lain : ...............................
12. Ekstremitas
a. Oedem : ya / tidak
b. Varises : ya / tidak
c. Nyeri : ya / tidak
V. PERENCANAAN TINDAKAN
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
..........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
..........................................................................................................................................................................................................
VI. PELAKSANAAN
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
..........................................................................................................................................................................................................
VII. EVALUASI
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
Mahasiswa
CI/Pembimbing Lahan
( ........................................................... ) ( ............................................................ )
Pembimbing Akademik
( ................................................................. )