FORMAT PENGKAJIAN IBU BERSALIN
No. Medrec : …………………….
Tgl.masuk : …………………….
Tgl & jam pengkajian : …………………….
Nama pengkaji : …………………….
A. IDENTITAS ISTRI SUAMI
Nama : ………………………………. ..........................................
Umur : ................................................. ..........................................
Suku : ................................................. ..........................................
Agama : ................................................. ..........................................
Pendidikan : ................................................. ..........................................
Pekerjaan : ................................................. ..........................................
Alamat : ................................................. ..........................................
................................................. ..........................................
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No. Tlp : ................................................. ..........................................
B. DATA SUBJEKTIF
- Alasan datang ke RS
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- Keluhan utama
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- Riwayat Obstetri
Riwayat Kehamilan Sekarang : G.................P................A...............
3.1.1. HPHT : ............................................................................
3.1.2. Gerakan janin : ............................................................................
3.1.3 Keluhan saat hamil muda :..........................................................................
... ......................................................................
...........................................................................
3.1.4. PNC : ............................................................................
............................................................................
3.1.5. Imunisasi TT : ............................................................................
3.1.6. Obat yang dikonsumsi : Obat (................................................................)
Jamu (................................................................)
Riwayat Haid
3.2.1. Menarche : …………………………………………
3.2.2. Siklus : …………………………………………
3.2.3. Lamanya : …………………………………………
3.2.4. Banyaknya : …………………………………………
3.3.5. Desmenorhoe : …………………………………………
Riwayat Kehamilan, nifas dan persalinan yang lalu
| Hamil Ke | Tgl Partus | Usia Kehamilan | Jenis partus | Penolong | Penyulit kehamilan & Persalianan | Anak | Nifas | |||
| JK | BB | PB | ASI | Penyulit | ||||||
| | | | | | | | | | | |
- Riwayat Ginekologi
4.1. Infertilitas : ....................................................................................................
4.2. Masa : ....................................................................................................
4.3. Penyakit : ....................................................................................................
4.4. Operasi : ....................................................................................................
- Riwayat KB
5.1. Kontrasepsi yang dipakai : ............................................................................
5.2. Keluhan : ……………………………………………........
5.3. Kontrasepsi yang lalu : …………………………………………............
5.4. Lamanya pemakaian : ……………………………………………........
5.5. Alasan berhenti : ............................................................................
- Riwayat Penyakit lainnya : …………………………………………………
…………………………………………………
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- Pola Nutrisi : Makan : .....X/hari (teratur /tidak teratur)
Pantang makan : ................................................
Minum : .............................................................
- Pola Eliminasi : BAB : ..............X/hari
BAK : .............X/hari
Masalah : ............................................................................
- Pola Tidur : Malam : ..................Jam
Siang : ..................Jam
Masalah : …………………………………………………
- Data sosial
Dukungan Suami :……………………………………..…………...
Dukungan keluarga : ............................................................................
Masalah : …………………………………………………
C. DATA OBJEKTIF
- Kesadaran
(__) Komposmentis
(__) Somnolent
(__) Sopor
(__) Sopor komatus
(__) Komatus
- Tanda-tanda Vital
Nadi ……………X/mnt
Suhu …………...X/mnt
Tensi …………..mmHg
Respirasi ……….X/mnt
- Kepala
Rambut : …………………………………………………………………
Mata : Konjungtiva : …………………………………………………
Sclera : …………………………………………………
Pengelihatan : …………………………………………………
Telinga : …………………………………………………………………
Hidung : …………………………………………………………………
…………………………………………………………………
Mulut : …………………………………………………………………
Leher : …………………………………………………………………
…………………………………………………………………
…………………………………………………………………
- Thorax
Dada : Bentuk simetri : Ya (__) Tidak (__)
Mamae : Bentuk simetris : Ya (__) Tidak (__)
Puting Susu : ………………………………………....
Benjolan : …………………………………………
Ekskresi : …………………………………………
Paru-paru : …………………………………………………………………
Jantung : …………………………………………………………………
- Abdomen
Inspeksi : Bentuk : …………………………………………………
Striae : ……………………………………....................
Bekas luka Operasi : ………………………………..................
Palpasi : Tinggi Fundus Uteri : ………… …Cm
Lingkar Perut : .................... Cm
Posisi Janin : Leopold I : ……………………………………...
Leopold II : ……………………………………..
Leopold III : …………………………………….
Leopold IV : ……………………………………
Kontraksi Uterus : frekuensi :……………………………….
Interval : ………………………………...
Intensitas : ………………………………
Auskultasi DJJ : .............................................................................................
Bising usus :…………………………………………………….
- Genetalia Luar
Bentuk : …………………………………………………………………
Varices : …………………………………………………………………
Oedema : …………………………………………………………………
Massa / Kista : ....................................................................................................
Pengeluaran pervigam : .......................................................................................
- Pemeriksaan dalam
Vulva / vagina : ....................................................................................................
Portio : ....................................................................................................
Pembukaan : ....................................................................................................
Ketuban : ....................................................................................................
Presentasi : ....................................................................................................
Penurunan Kepala (5/5): ......................................................................................
- Ekstremitas (tangan & kaki)
Bentuk : Kaki : ................................. Tangan : .......................................
Kuku : Kaki : ................................ Tangan : .......................................
Refleks Patela : ................................
Oedema : ................................
- Kulit
Warna : ....................................
Turgor : ....................................
- Data Penunjang (LABORATORIUM)
a. Pemeriksaan urine
Protein : .........................................
Reduksi : .........................................
Urobilin : .........................................
Bilirubin : .........................................
b. Pemeriksaan darah
Hb : .............................
Golongan darah : .............................
VDRL : .............................
c. Pemeriksaan pap smear
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d. Pemeriksaan lain-lain bila diperlukan
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D. ANALISA / DIAGNOSA MASALAH
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E. PERENCANAAN
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F. PENATALAKSANAAN
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G. EVALUASI
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