No RM :.....................
Masuk tgl/jam :.....................
1.
Identitas Istri Suami
Nama :...................... .........................
Umur :...................... ..........................
Agama :...................... ..........................
Pendidikan :...................... ..........................
Pekerjaan :...................... ...........................
Suku/bangsa:..................... ...........................
Alamat :....................... ...........................
Telp :........................ ...........................
3
Anamnesa
a.
Keluhan
utama
.............................................................................................................................
b.
Riwayat
perkawinan
Perkawinan ke..................menikah sejak umur..........................................................
Lama perkawinan.......................................................................................................
c.
Riwayat haid
Menarche.....................HPM......................................................................................
HPL..................................................lama..................................................................
Teratur/tidak..................................................sakit/tidak............................................
Siklus..........................................................................................................................
d.
Riwayat
Obstetri
G.............P............A.............
no
|
Th
|
Jenis
persalinan
|
penolong
|
tempat
|
H/M
|
Jenis
|
BB lahir
|
Komplikasi
|
Ket
|
e . Riwayat
KB
No
|
PASANG
|
LEPAS
|
||||||||
metode
|
tgl
|
petugas
|
tempat
|
Ket
|
tgl
|
petugas
|
tempat
|
alasan
|
ket
|
|
f. Riwayat Kesehatan
a)
Riwayat
Kesehatan Yang Lalu
b)
Riwayat
Kesehatan Sekarang
c)
Riwayat Kesehatan
Keluarga : riwayat persalinan
Kembar baik dari keluarga ibu maupun
suami
g. Riwayat Kesehatan Sekarang
ANC
di....................sejak umur
kehamilan.....................................................................
Gerakan
pertama kali dirasakan pada umur kehamilan....................................................
Gerakan
janin selama 2 jam.............................................................................................
Frekuensi periksa TM I..............TM II..........................TM III......................................
Senam hamil.....................................................................................................................
Riwayat Imunisasi TT Catin :..........................................................................................
Imunisasi TT : pernah / tidak :.........................................................................................
Imunisasi TT 1 tgl ..........................................TT
11 tgl..................................................
Pendidikan Kesehatan yang diperoleh
:
Trimester
|
Materi
pendidikan kesehatan
|
I
|
|
II
|
|
III
|
Permasalahan dan Keluhan dalam
kehamilan
Trimester
|
Masalah/keluhan
|
Tindakan/terapi
|
I
|
||
II
|
||
III
|
h. Pola Kebutuhan Sehari-hari
a) Nutrisi
Pola makan sehari-hari :........................................................................................
Jenis :........................................................................................
Makanan pantangan :........................................................................................
Pola minum :.........................................................................................
Masalah :.........................................................................................
b)
Eliminasi
a.
BAK
Frekuensi............................Jumlah..............................warna...............................
Keluhan.................................................................................................................
b. BAB
Frekuensi................................jumlah.....................................warna.....................
Keluhan.................................................................................................................
c.
Istirahat
Siang............................................Malam........................................................
Keluhan...........................................................................................................
d.
Aktifitas :.........................................................................................
e.
Personal
higiene :.........................................................................................
f.
Pola seksual :........................................................................................
i.
Data
Psikososial Spiritual
Tanggapan ibu dan keluarga
Terhadap kehamilan :.................................................................................
Pengetahuan ibu dan keluarga
Tentang kehamilan :....................................................................................
Pengmbilan keputusan oleh :............................................................
Ketaatan ibu beribadah :.................................................................
Ibu tinggal bersama :.................................................................
Hewan piaraan :.................................................................
Rencana melahirkan di :...............................................................
B. Data objektif
1.
Pemeriksaan Umum
KU :.........................................................................................
Kesadaran :.........................................................................................
TB :.........................................................................................
BB
: Sebelum hamil :............................................................
Kunjumgan yang lalu :....................................................
Sekarang :.........................................................................................
Lila :.........................................................................................
Vital
sign : T:.................N:..................S:.....................R:...............
2.Pemeriksaan
fisik
Kepala :........................................................................................
Muka :.........................................................................................
Mulut :........................................................................................
Gigi :.........................................................................................
Mata :.........................................................................................
Telinga :.........................................................................................
Hidung :.........................................................................................
Leher :.........................................................................................
Aksila :........................................................................................
Dada :.........................................................................................
Payudarah :.........................................................................................
3.Pemeriksaan Obstetri
Abdomen
: TFU :............................................................................. LI :.............................................................................
LII :.............................................................................
LIII :.............................................................................
LIV :.............................................................................
TBBJ :.............................................................................
D JJ :.........................................................................
Puktum
maksimu
Pemeriksaan
panggul luar : terutama primi
gravida ( bila ada indikasi)
Genetalia : Inspeksi /inspekulo (bila da indikasi)
Ekstremitas :Oedema,
refleksi, varises (kanan/kiri)
4.Pemeriksaan penunjang
a.
USG : tgl ............../hasil...................................................................................
ib. Lab :
a)
Urine : tgl..............................(PP
test, Protein,Glukosa dll)
b) Darah :tgl................................(Hb, Al,
HMT, Golongan dara )
II Interpreasi
data
A.
Diagnosa
Kebidanan :
·
Untk ibu
hamil usia rreproduksi sehat :
Contoh : Seorang ibu primigravida
usia reproduksi sehat
·
Untuk ibu
hamil usia reproduksi tidak sehat (umur <20 th/>35th):
Contoh : Seorang ibu primigravida
usia reproduksi tidak sehat hamil..............minggu..............hrari keadaan ibu dan
janin normal dengan faktor resiko.
Data dasar : DS : Ibu mengatakan................................................................
D O : VS, LILA,
palpasi Leopod, DJJ, Px penunjang
B.
Masalah
Data-data yang ditemukan diluar
diagnosa kebidanan dan berhubungan dengan ketidaknyamanan pasien(eks :
cemas,KTD, makanan pantangan dan penyakit diluar kebidanan , dan lain-lain)
Data dasar : DS/DO
III. DIAGNOSA POTENSIAL
Untuk
hamil normal atau tidak ada
Potensial
: keadaan yang harus dilkukan segera.
IV. ANTISIPASI MASALAH / TINDAKAN
SEGERA
Untuk
hamil normal tidak ada
V. PERENCANAAN
Tanggal
/jam
VI. PELAKSANAAN
Tanggal/jam
VII.
EVALUASI
Tanggal/jam
CATATAN PERKEMBANGAN
Tanggal.........................................................................Jam.......................................
DATA SUBJEKTIF
.........................................................................................................................................................................................................................................................................................................................................................................................................
DATA OBJEKTIF
.........................................................................................................................................................................................................................................................................................................................................................................................................
ASSESMENT
.........................................................................................................................................................................................................................................................................................................................................................................................................PLANNING
........................................................................................................................................................................................................................................................................................................................................................................................................