Professional Documents
Culture Documents
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RS/PUSKESMAS/RB/BPS
NO.RM
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TANGGAL MASUK :
PUKUL
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RUANGAN
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PENGUMPULAN DATA
A. IDENTITAS
Nama Ibu
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat Kantor
Alamat Rumah
Telp
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Penanggung Jawab
Nama
Umur
Pekerjaan
Alamat
No. Telp/HP
Hubungan dengan klien
Nama Suami
Umur
Suku/Bangsa
Agama
Pendidikan
Pekerjaan
Alamat Kantor
Alamat Rumah
Telp
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B. ANAMNESA
Pada Tanggal
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Pukul
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Cara masuk
: datang sendiri / kiriman
1. Keluhan Utama
2. Tanda-tanda bersalin
Kontraksi.......................sejak tanggal..........................pukul....................................
Frekuensi .......................x setiap 10 menit
Lamanya ........................detik kekuatan...................................................................
Lokasi ketidaknyamanan...........................................................................................
3. Pengeluaran pervaginam
Darah lendir
ada tidak, tanggal...................pukul...........................
Air ketuban
ada
tidak, jam........................jumlah..........................
Warna...................................bau...................................
Darah
ada
tidak, jam.......................jumlah..........................
Warna................................
4. Masalah masalah khusus
:.............................. TP
:.................................
:.............................. Lamanya :.................................
:..............................
: Teratur / tidak, frekuensi................x di..................
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No
Tgl/Thn
persalinan
Tempat
Pertolongan
Usia
kehamilan
Jenis
Persalinan
Penolong
Penyakit
kehamilan &
persalinan
Anak
JK
BB
PB
keadaan
:..............................................................................................
Denyut nadi
Pernafasan
Suhu tubuh
3. Tinggi Badan
4. Muka
:..............................................................................................
:..............................................................................................
:..............................................................................................
:.....................................Berat Badan.....................................
: Kelopak Mata
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Konjungtiva
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Sklera
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Mulut dan gigi
: Lidah dan geraham
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Gigi
:..............................................
Kelenjar Thiroid
: pembesaran
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Kelenjar Limfe
: pembesaran
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Dada
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Jantung
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Paru
:..................................................................................
Payudara
: Pembesaran
:..............................................
Papila Mammae
:..............................................
Simetris
:..............................................
Benjolan
:..............................................
Pengeluaran
:..............................................
Rasa Nyeri
:..............................................
Punggung dan pinggang
:..................................................................................
Posisi tulang belakang
:..................................................................................
Pinggang/ nyeri ketuk
:..................................................................................
Ekstremitas atas dan bawah : Oedema
:..................................
Kekakuan otot & sendi
:..................................
Kemerahan
:..................................
Varises
:..................................
Reflek
:..................................
Abdomen
: Pembesaran
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Benjolan
:..............................................
Bekas luka operasi :..............................................
Konsistensi
:..............................................
Pembesaran lien/limfe
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Kandung Kemih
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5. Pemeriksaan kebidanan
1) Palpasi Uterus
Leopold I
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( dengan pita cm )
:.....................................TBJ......................................
Leopold II
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Leopold III
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Leopold IV
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Pergerakan
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Kontraksi
: Frekuensi........./10, lama............kekuatan.............
2) Auskultasi
Denyut Jantung Janin
Frekuensi
Punctum maksimum
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:..........................Teratur/Tidak......................
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4) Pemeriksaan Dalam
Atas indikasi
Dinding vagina
Porsio
Pembukaan serviks
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:....................Konsistensi...............,posisi......
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Ketuban
Presentasi Serviks
Penurunan bagian terendah
Penunjuk ( Point Of Direction )
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Pemeriksaan panggul
Promontorium...............................................Linea inominata.............................
Konjungata vera..........................................Konjungata Diagonalis....................
Sacrum..........................................Dinding Samping...........................................
Spina ischiadica........................................................Distansia Interspinarum.....
...............................................,Koksigeus............................................................
Arcus Pubis.......................................Distansia Intertuberosum..........................
D. UJI DIAGNOSTIK
Pemeriksaan laboratorium
CT/CB
Hemoglobin
Golongan Darah
Haemotokrit
Rhesus
DII ( Sesuai Kebutuhan )
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