I. DATA DEMOGRAFI
Nama klien :
Umur klien :
Jenis kelamin :
Nama suami :
Umur suami :
Alamat :
Status perkawinan :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Diagnosa medik :
Tgl masuk RS :
No RM :
No RM :
Tgl pengkajian :
II. KELUHAN UTAMA SAAT INI
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III. RIWAYAT PENYAKIT DAHULU
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IV. RIWAYAT PERSALINAN DAN KELAHIRAN SAAT INI
Kondisi Kehamilan_______ : G_P_A_, HPM:__________, HPL : ______________, UK: __ minggu, TFU: __ cm, TBJ: ____gr, _________________________________________________________
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Proses Persalinan_______ : ________________________________________________________
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Dengan anestesi + analgetik: ________________________________________________________
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Kondisi bayi setelah lahir__ : bayi ___________ dengan BBL: ______ gr, PB : ____ cm, LK/LD: ___cm/___cm. A/s : __/___
Plasenta_______________ : ukuran (__x___x___)cm. berat ____ gr, panjang tali pusat: ___cm.
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Jumlah Perdarahan : ____ cc
V. DATA BAYI SAAT INI
- Jenis kelamin : ________________________________________________________
- Berat badan lahir : ____________________________________________________ gram
- Lingkar kepala : _____________________________________________________ cm
- Lingkar dada : _____________________________________________________ cm
- Panjang badan : _____________________________________________________ cm
- Lingkar lengan atas : _____________________________________________________ cm
| APGAR SCORE | 1 Menit | 5 menit |
| Denyut jantung Pernafasan Tonus otot Peka rangsang Warna kulit | | |
| Jumlah | | |
VI. KEADAAN PSIKOLOGIS IBU
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VII. RIWAYAT PENYAKIT KELUARGA
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VIII. RIWAYAT GINEKOLOGI
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IX. RIWAYAT OBSTETRI
Usia menarche : ________________________________________________________
Siklus menstruasi : ________________________________________________________
Lamanya menstruasi : ________________________________________________________
G__ P____ A___
Umur kehamilan : __________________________________________________ minggu
Riwayat pemakaian kontrasepsi : _____________________________________________________
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X. REVIEW OF SYSTEM DAN PEMERIKSAAN FISIK
Penampilan umum : _______________________________________________________________
Kesadaran ______________________________________________________________________
Tinggi badan __________________________________________________________________ cm
Berat badan : _________kg (selama hamil) sebelum hamil (______________________________ kg)
Vital sign :TD : _____ mmHg N : _______ x/menit S : _____ o C RR : _______ x/menit
| Komponen | Review of sistem | Pemeriksaan fisik |
| Kulit, rambut, kuku | | |
| Kepala, mata, dan leher | | |
| Telinga | | |
| Mulut, tenggorokan dan hidung | | |
| Thoraks dan paru | | |
| Payudara | | |
| Jantung | | |
| Abdomen | | |
| Genetalia | | |
| Anus dan rektum | | |
| Muskuloskeletal | | |
I. RIWAYAT KESEHATAN
| Komponen | Hasil |
| Pola persepsi kesehatan. | |
| Pola nutrisi dan metabolik | |
| Pola eliminasi | |
| Pola aktivitas latihan | |
| Pola istirahat dan tidur | . |
| Pola persepsi-kognitif | |
| Pola persepsi diri | |
| Pola hubungan - peran | |
| Pola seksualitas - reproduksi | |
| Pola stress - koping | |
| Pola kepercayaan dan nilai-nilai | |
II. PEMERIKSAAN LABORATORIUM DAN PEMERIKSAAN PENUNJANG LAINNYA
| Tanggal dan jenis pemeriksaaan | Nilai | Interpretasi |
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III. TERAPI MEDIS
| Tgl | Jenis terapi | Rute | dosis |
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