TINJAUAN KASUS Tanggal : ...................... Jam : ........................WIB LANGKAH I (PENGKAJIAN DATA) A. DATA SUBYEKTIF 1. Identitas Nama Umur Agama Pendidikan Pekerjaan Alamat a. Isteri - Perkawinan ke- Umur kawin - Lama kawin 3. Alasan Kunjungan ............................................................................................................................... ............................................................................................................................... 4. Riwayat Kebidanan a. Haid : ................................. : ................................. : ................................. : ................................. : ................................. : ................................. - Menarche - Siklus/lama - Banyaknya - Warna/bau - Dismenorrohoe - Flour Albus : .............. : .............. : .............. : .......................... : .......................... : .......................... : .......................... : .......................... : .......................... Penanggung jawab/Suami Nama Umur Agama Suku/Bangsa Pendidikan Pekerjaan Alamat b. Suami : .............. : .............. : .............. : ....................... : ....................... : ....................... : ....................... : ....................... : ....................... : ....................... Tempat : .............................

Suku/Bangsa : ..........................

2. Status Perkawinan - Perkawinan ke- Umur kawin - Lama kawin

- HPHT - UK b. Perk awin an keKe UK Jns Penol Tm pt Kehamilan

: ............................ TP : ........................ : .................................

Riwayat Kehamilan, Persalinan dan Nifas yang lalu Persalinan Anak Peny Se . x BBL Hid up Nifas Ma AS ti I Pen y KB

c.

Riwayat Kehamilan Sekarang ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................

5. Riwayat Kesehatan Yang Lalu ............................................................................................................................... ............................................................................................................................... ...............................................................................................................................

6. Riwayat Kesehatan Keluarga ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... 7. Riwayat Psikososial ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... 8. Riwayat Sosial Budaya ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... 9. Pola Kebiasaan Sehari-hari a. Pola nutrisi Sebelum hamil : Makan : Minum : Selama hamil : Makan : ......................................................................... Minum :

b. Pola eliminasi Sebelum hamil : BAB : BAK: ......................................................................................... ......................................................................................... Selama hamil : BAB BAK : :

c. Aktivitas Sebelum Selama d. Pola istirahat Sebelum hamil : Tidur siang : ....................................... Tidur malam : ..................................... Selama hamil : Tidur siang e. Personal hygiene

hamil : ............................................................................................ hamil : ............................................................................................

: .......................................

Tidur malam : ....................................... Sebelum hamil : .............................................................................................. .............................................................................................. .............................................................................................. ..............................................................................................

Selama hamil : ................................................................................................ ................................................................................................ ................................................................................................ ................................................................................................

f. Pola seksual Sebelum hamil : ............................. Selama hamil : ............................... B. DATA OBYEKTIF 1. Pemeriksaan Fisik Umum a. Keadaan Umum - Kesadaran - Postur tubuh - Cara berjalan - BB sebelum hamil - BB saat ini : .............................. : .............................. : .............................. : .............................. : ..................... kg : ..................... kg

- Kenaikan - TB/LILA b. TTV : T : ........ mmHg S : ........C 2. Pemeriksaan Fisik Khusus a. Inspeksi

: ..................... kg : ............cm/............cm N : ........ x/mnt RR : ..... x/mnt

Kepala : ....................................................................................................... Muka Mata : : ....................................................................................................... ..................................................................................................... ..................................................................................................... Hidung : ....................................................................................................... ..................................................................................................... Mulut : ....................................................................................................... ..................................................................................................... Telinga : ....................................................................................................... ....................................................................................................... Leher : ....................................................................................................... ....................................................................................................... : .......................................................................................................

Dada

Mammae : ..................................................................................................... ...................................................................................................

................................................................................................... ................................................................................................... Abdomen : ..................................................................................................... ................................................................................................... Genetalia Eksterna :

Anus

: ....................................................................................................... ....................................................................................................... ....................................................................................................... :

Ekstremitas Atas

Bawah :

b. Palpasi Kepala : ..................................................................................................... Leher : ....................................................................................................... ..................................................................................................... Ketiak : ....................................................................................................... ....................................................................................................... Mammae : .....................................................................................................

Abdomen : ................................................................................................... ................................................................................................... ................................................................................................... ................................................................................................... LI : ................................................................................................... ................................................................................................ ................................................................................................ ................................................................................................ LII : ................................................................................................ ................................................................................................ ................................................................................................ LIII LIV TBJ Ekstremitas Atas : ....................................................................................................... : ................................................................................................ : ................................................................................................ : ..................... gr.

Bawah : ....................................................................................................... c. Auskultasi

Dada Abdomen : DJJ :

: .............................. = .........x/menit

d. Perkusi

e. Pemeriksaan Ukuran Panggul Luar (UPL)

f. Kesimpulan ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... LANGKAH Diagnose : ............................................................................................................ ............................................................................................................ DS : II (IDENTIFIKASI DIAGNOSA, MASALAH DAN

KEBUTUHAN)

DO

:

Masalah : Data Subyektif : Data Obyektif : Kebutuhan : .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... LANGKAH III (ANTISIPASI MASALAH POTENSIAL) ............................................................................................................................... LANGKAH IV (IDENTIFIKASI KEBUTUHAN SEGERA) ............................................................................................................................... LANGKAH V (INTERVENSI) Diagnose : ...............................................................................................................

............................................................................................................ Tujuan : ............................................................................................................ ............................................................................................................ Criteria :

Intervensi : 1. .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 2. .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 3. .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 4. .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 5. .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... LANGKAH VI (IMPLEMENTASI)

Tanggal : .......................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ...............................................................................................................................

............................................................................................................................... ............................................................................................................................... LANGKAH VII (EVALUASI) Tanggal : .......................... Diagnose : ............................................................................................................ ............................................................................................................ S : ........................................................................................................................ ........................................................................................................................ O : ........................................................................................................................ ........................................................................................................................ A : ........................................................................................................................ ........................................................................................................................ P : ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ Jam : .........WIB