tinjauan kasus- anc format
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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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