FRM 02.03
PEMERINTAH KABUPATEN KEPULAUAN YAPEN
RUMAH SAKITUMUM DAERAH SERUI Alamat : Jl.Pertanian, Wainakawini, Serui – Papua. (0983) 33871 - a! (0983) 333"" #-mail : r$u%$erui&'mail.m
Nomor RM
: ………………………………
Nama
: ………………………………
Jeni Jeniss Kela Kelami min n
: Laki Laki-l -lak akii / Pere Peremp mpua uan n
(coret yang dak sesuai
!anggal La"ir
: ………………………………
(mo"on diisi atau tempelkan tempelkan sker #ika ada
PENGKAJIAN AWAL PASIEN KEBIDANAN DAN KANDUNGAN RIWAYAT KEPERAWATAN !anggal anggal masuk masuk R$ : %%%%%% %%%%%%%%% %%%%%% %%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%% %%%%% !angg anggal al Pengk engka# a#ia ian n : %%%% %%%%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %% Ru#ukan : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Masuk Masuk Melalu Melaluii Ruan Ruang gan/K an/Kel elas as )iagnosa Medis
: Klinik Klinik Ke&/' Ke&/') ) : %%%% %%%%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %% : %%%%%%%%%%%%%%%%%%%%%%%%%%
ALERGI/REAKSI !idak ada alergi lergi lergi 2&at3 se&utkan se&utkan ler lergi gi mak makanan anan33 se&u se&utk tkan an lergi lainnya3 se&utkan
:%%%%%%%%%%% :%%%%%%%%%%%%%%%%% %%%%%%%%%%%% %%%%%%%%%%%% %%%%%%%% %% Reaksi Reaksi %%%%%%%%%%% %%%%%%%%%%%%%%%%%% %%%%%%%%% %% :%%% :%%%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %% Reak Reaksi si %%%% %%%%%% %%%% %%%% %%%% %%%% %%%% %%%% %%%% %% :%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Reaksi %%%%%%%%%%%%%%%%%%%%% Merah” Bila pasien alergi gunakan gel ang “ Merah
ALASAN MASUK RUMAH SAKIT / KELUHAN UTAMA: UTAMA: %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% RIWAYAT KESEHATAN/PENGOBATAN YANG LALU : Ri*ay Ri*ayat at dira* dira*at at di R$ : %%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%%%% %%%%%% %% alasan alasan dira* dira*at at : %%%%%% %%%%%%%%%% %%%%%%%% %%%%%%%% %%%%%%% %%% *aktu *aktu/la /lama ma : %%%%%% %%%%%%%%% %%%%%% %%%%%% %%%%%% %%%%%% %%% Ri*ay Ri*ayat at opera operasi si !idak !idak +a #enis #enis opera operasi si : %%%%%% %%%%%%%%% %%%%%%% %%%%%%%% %%%%%%%% %%%%%% ta"un ta"un opera operasi si :%%%%% :%%%%%%%% %%%%%% %%%%%% %%%%%% %%% Ri*ayat Ri*ayat kecelakaan kecelakaan : %%%%%%%%%%%%%%%%%%%%%% RIWAYAT REPRODUKSI WANITA : ,') : Menarc"e :………………%ta"un :………………%ta"un $iklus :…………………………………………%"ari :…………………………………………%"ari Lama "ai :………………%"ari ,ari pertama "aid terak"ir :………………%% P.RK'NN :………………%kali )engan suami sekarang sekarang :………………%%ta"un :………………%%ta"un RIWAYAT OBSTETRI NO
TAHUN LAHIR
JENIS KELAMIN/ BB
RIWAYAT RIWAYAT SOSIAL SOS IAL Merokok :
UMUR KEHAMILAN
JENIS PERSALINAN
PENOLONG PERSALIN
TEMPAT PERSALINAN
PENYULIT
HIDUP MATI
: !idak
+a………………………%0atang/"ari $e#ak usia……………$elama… usia…………… $elama………! ……!a"um a"um 0er"en…………………%ta"un 0er"en…………… ……%ta"un Konsumsi psikotropika : &use !erapeuk Konsumsi alco"ol :……………………………………………%%gelas :……………………………………………%%gelas per "ari/&ulan/ta"un KEHAMILAN SEKARANG : !aksiran tanggal persalinan :…………………………………%0uku :……………………… …………%0uku K' : +a / !idak Penga*asan Penga*asan ke"amilan : +a )i………………………………………% )i………………… ……………………% !idak KELUARGA KELUARGA BERENCANA (KB) SELAMA KEHAMILAN INI : +a / !idak 1aranya :……………………………………………………… :……………………… ………………………………%Lamanya %Lamanya :………………………………………………%% :…………………………… …………………%% 'ngin anak :………………………………………………………%'ngin :………………………………………………………%'ngin K0 :………………………………………………% :………………………………………………% Keterangan Keterangan : Pendidikan suami:…………………………%Peke suami:…………………………%Peker#aan r#aan suami :…………………………………… :…………………………………… Pendidikan 'stri :…………………………%%Peker#aan :…………………………%%Peker#aan istri :………………………………… :…………………………………%% %%
PEMERIKSAAN FISIK STATUS GENERALIS Keadaan 4mum : ………………………… RR : ………………………… 5/mnt Kesadaran : ………………………… Nadi : ………………………… 5/mnt !ekanan )ara" : ………………………… mm,g $u"u : ………………………… o1 $kala Nyeri : ………………………… Resiko Jatu" : !idak &eresiko Resiko Renda" Resiko !inggi Pasien Mengalami Peningkatan 0erat 0adan 6 7 8 kg 66 7 68 kg 9 7 6 kg ;69 kg Kon#unc
Normal $ianosis Pucat
RESPIRASI Pola Napas !eratur !idak teratur PAYUDARA !idak ada &en#olan da &en#olan3se&utkan %%%%%%%%%%%% ABDOMEN )atar Lem&ut 1em&ung Lem&ut )istensi &domen
!idak pucat Pucat
!idak
ikterik 'kterik
)yspnoe
"ee=eng %%%%%%%%%%%%%% /%%%%%%%%%%%%%%
2rt"opnoe
PUTING SUSU Menon#ol )atar
COLUSTRUM da !idak ada
Luka &ekas operasi $trie ra
Kontraksi Keras Lem&ek
GASTROINSTESTINAL Mampu makan sendiri !idak ada kelu"an !ak ada na>su makan Pem&atasan makan3 se&utkan: %%%%%%%%%%%%
Mual Munta" !erpasang N! igi palsu : gigi atas3 gigi &a*a" M!" : Kandung kemi" kososng Kandung kemi" penu" Menggunakan pampers Menggunakan kateter3 se&utkan #enis3 ukuran3 tgl Pemakaian %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
ELIMINASI )e?kasi : Normal !idak Normal3 se&utkan:%%%%%%%%%%%%%
EKSTERMITAS ,angat
.dema
)ingin
!idak ada keter&atasan >ungsi da keter&atasan >ungsi3 se&utkan reanya : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$ianosis
STATUS OBSTRETRI Pemeriksaan Luar : !inggi >undus uteri :……………………cm Letak #anin : )etak #antung #anin : !idak ada
!a>siran &erat #anin :……………………%%gram ,'$ :
da
(teratur/dak3 @rekuensi:…………%5/mnt
!idak
ada da (teratur/dak @rekuensi:…………%5/mnt
Pemeriksaan dalam : Pem&ukaan………………%cm Kulit ketu&an 0agian &a*a" kepala / &okong / ekstremitas /………………% !urun ,odge Kesan panggul $erui3 !anggal………………………………%%Jam……………% !anda !angan )okter
$erui3 !anggal…………………Jam…………… !anda !angan 0idan
Nama :
Nama :
