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 TINJAUAN KASUS

I. PENGKAJIAN

Tempat :

Tanggal : Jam : WIB

A.  Data Subyektif 

1. Biodata

Nama istri : .............................

Umur : .............................

Agama : .............................

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

Pendidikan : .............................

Pekerjaan : .............................

Penghasilan : .............................

Umur kawin : .............................

Kawin ke : .............................

Lama kawin : .............................

Alamat : .............................

Nama suami : .............................

Umur : .............................

Agama : .............................

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

Pendidikan : .............................

Pekerjaan : .............................

Penghasilan : .............................

Umur kawin : .............................

Kawin kawin : .............................

Lama kawin : .............................

Alamat : .............................

2. Keluhan utama

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3.  Riwayar Kesehatan Sekarang

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4. Riwayat Kesehatan yang Lalu

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5. Riwayat Keluarga

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6. Riwayat Kebidanan

a. Riwayat Haid

Menarche : ........................................................................................................

Siklus : ........................................................................................................

Lama : ........................................................................................................

Jumlah : ........................................................................................................

Warna : ........................................................................................................

Keluhan : ........................................................................................................

Konsistensi : ........................................................................................................

Flour Albus : ........................................................................................................

Kapan : ........................................................................................................

b. Riwayat kehamilan sekarang

Hamil ke : .........................

HPHT :..........................

UK :..........................

ANC : TM I : ......x bidan/ dokter

Keluhan : ............................................................

Terapi : ............................................................

Penyuluhan : ............................................................

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TM II : .......x bidan/ dokterKeluhan : ............................................................

Terapi : ............................................................

Penyuluhan : ............................................................

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 TM III : .......x bidan/ dokter

Keluhan : ............................................................

Terapi : ............................................................

Penyuluhan : ............................................................

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TT : ....................................................................................................................

Gerakan janin : ....................................................................................................................

7. Pola Kebiasaan Sehari- hari

a. Nutrisi

Sebelum hamil :...................................................................................................................

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

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b.Eleminasi

Sebelum hamil :...................................................................................................................

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

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c. Istirahat/tidur

Sebelum hamil :...................................................................................................................

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

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d. Personal hygiene

Sebelum hamil :...................................................................................................................

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

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e. Aktivitas

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 Sebelum hamil :...................................................................................................................

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

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f. Seksual

Sebelum hamil :...................................................................................................................

Selama hami :...................................................................................................................

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5. Keadaan Psikososial

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6. Keadaan Sosial Budaya

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B.  Data Objektif 

Keadaan umum : .............................

Kesadaran : .............................

Poster tubuh : .............................

Cara berjalan : .............................

Tinggi Badan : .............................

BB sebelum hamil : .............................

BB sekarang : .............................

Kenaikan BB : .............................

LILA : .............................

TTV : TD : ............................. S : .....................

N : ............................. RR : .....................

a.  Pemeriksaan fisik 

1) Inspeksi

a) 

Kepala : ...............................................................................................................................................................................................................

b)  Muka : .......................................................................................................

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 c)  Mata : .......................................................................................................

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d)  Hidung : .......................................................................................................

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e)  Mulut & gigi : .......................................................................................................

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f)  Telinga : .......................................................................................................

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g)  Leher : .......................................................................................................

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h)  Axilla : .......................................................................................................

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i)  Mammae : .......................................................................................................

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 j)  Abdomen : .......................................................................................................

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k)  Genetalia : .......................................................................................................

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l)  Anus : .......................................................................................................

m)  Ekstremitas Atas: ................................................................................................. :

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n)  Ekstremitas Bawah: .............................................................................................

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2) Palpasi

a) Leher : .......................................................................................................

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b) Axilla : ......................................................................................................

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c) Mammae : .......................................................................................................

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 d)  Abdomen :

Leopold I : .....................................................................................................

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Leopold II : ....................................................................................................

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Leopold III : ....................................................................................................

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Leopold IV : ....................................................................................................

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TFU MC Donald : ....................................................................................................

TBJ : ....................................................................................................

e). Genetalia : .....................................................................................................

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f). Ektremitas Atas : ......................................................................................................

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g). Ektremitas Bawah: ....................................................................................................

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3)  Auskultasi

a. Dada : ...............................................................................................................

b. Abdomen : ............................................................................................................

c. DJJ : ..............................................................................................................

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4) Perkusi

Reflek patella : ..............................................................................................................

b.  Pemeriksaan penunjang

Hb : .....

Protein urin : .....

Glukosa urin : ......

c. Pemeriksaan panggul luarDistansia spinarum : .............

Distansia cristarum : .............

Konjungata eksterna : .............

Lingkar panggul : .............

II. IDENTIFIKASI DIAGNOSA/ MASALAH KEBUTUHAN

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 Tanggal : Jam : WIB

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III. ANTISIPASI MASALAH POTENSIAL

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IV. IDENTIFIKASI KEBUTUHAN SEGERA

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V. INTERVENSI

Tanggal : Jam: WIB

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VI. IMPLEMENTASI

Tanggal : Jam : WIB..............................................................................................................................................................

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VII. EVALUASI

Tanggal : Jam : WIB

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