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<!DOCTYPE html>
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<head>
<title>ASESMEN KEBIDANAN</title>
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<body>
<table border="0">
<tr>
<td width="25%"><img src="https://daftar.rsaulia.com/assets/img/logo-new.png" width="150"></td>
<td width="50%"> </td>
<td width="25%">
<table border="1">
<tr>
<td>NO FORM : FR.RB.01-49</td>
</tr>
<tr>
<td>NO REV : 01</td>
</tr>
</table>
</td>
</tr>
</table>
<table border="0">
<tr>
<td width="50%" rowspan="4" align="center" valign="middle"><h1><B>ASESMEN KEBIDANAN</B></h></td>
<td width="20%">Nama</td>
<td width="2%">:</td>
<td width="28%">..............................</td>
</tr>
<tr>
<td>No RM</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr>
<td>Tgl. Lahir</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr>
<td colspan="3"><i>Harap diisi atau menempelkan stiker bila perlu</i></td>
</tr>
</table>
<center><h2><B>I. ANAMNESA/PENGKAJIAN</B></h2></center>
<table border="0">
<tr valign="top">
<td colspan="4">
Petunjuk :<br>
Beri tanda ( v ) pada kolom yang sesuai<br>
</td>
</tr>
<tr valign="top">
<td width="2%">1.</td>
<td width="29%">Tiba di ruangan</td>
<td width="1%">:</td>
<td width="69%">
<table border="0">
<tr valign="top">
<td width="19%">Tanggal</td>
<td width="1%">:</td>
<td width="30%">..............................</td>
<td width="19%">Pukul</td>
<td width="1%">:</td>
<td width="30%">..............................</td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>2.</td>
<td>Pengkajian</td>
<td>:</td>
<td>
<table border="0">
<tr valign="top">
<td width="19%">Tanggal</td>
<td width="1%">:</td>
<td width="30%">..............................</td>
<td width="19%">Pukul</td>
<td width="1%">:</td>
<td width="30%">..............................</td>
</tr>
<tr>
<td>Diperoleh dari</td>
<td>:</td>
<td colspan="4">............................................................</td>
</tr>
<tr>
<td>Hubungan dengan pasien</td>
<td>:</td>
<td colspan="4">............................................................</td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>3.</td>
<td>Cara Masuk</td>
<td>:</td>
<td>
<table border="0">
<tr valign="top">
<td>
<input type="checkbox"> Jalan dengan bantuan<br>
<input type="checkbox"> Menggunakan kursi roda<br>
<input type="checkbox"> ..............................
</td>
<td>
<input type="checkbox"> Jalan tanpa bantuan<br>
<input type="checkbox"> Menggunakan stretcher
</td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>4.</td>
<td>Hambatan dalam bahasa </td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya
</td>
</tr>
<tr valign="top">
<td> </td>
<td>Perlu penerjemah</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya
</td>
</tr>
<tr valign="top">
<td>5.</td>
<td>Keluhan Utama</td>
<td>:</td>
<td>........................................................................................................................</td>
</tr>
<tr valign="top">
<td> </td>
<td>Riwayat Kesehatan Sekarang (Alasan Masuk RS)</td>
<td>:</td>
<td>
........................................................................................................................<br>
........................................................................................................................<br>
........................................................................................................................<br>
</td>
</tr>
<tr valign="top">
<td>6.</td>
<td>Riwayat kesehatan yang lalu , pernah opname</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya
</td>
</tr>
<tr valign="top">
<td> </td>
<td>Kapan opname terakhir</td>
<td>:</td>
<td>........................................................................................................................</td>
</tr>
<tr valign="top">
<td>7.</td>
<td>Riwayat penyakit dahulu<br>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya<br>
</td>
<td>:</td>
<td>
<input type="checkbox"> Hepatitis
<input type="checkbox"> DM
<input type="checkbox"> Jantung
<input type="checkbox"> Anemia <br>
<input type="checkbox"> Hipertensi
<input type="checkbox"> Asma
<input type="checkbox"> HIV/AIDS
<input type="checkbox"> ..............................
</td>
</tr>
<tr valign="top">
<td>8.</td>
<td>Riwayat penyakit keluarga<br>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya<br>
</td>
<td>:</td>
<td>
<input type="checkbox"> Hepatitis
<input type="checkbox"> DM
<input type="checkbox"> Jantung
<input type="checkbox"> Anemia <br>
<input type="checkbox"> Hipertensi
<input type="checkbox"> Asma
<input type="checkbox"> HIV/AIDS
<input type="checkbox"> ..............................
</td>
</tr>
<tr valign="top">
<td>9.</td>
<td>Alat kesehatan yang terpasang
</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, Jenis ..............................
</td>
</tr>
<tr valign="top">
<td>10.</td>
<td>Apakah pernah operasi
</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, Jenis ..............................
</td>
</tr>
<tr valign="top">
<td>11.</td>
<td>Riwayat Alergi
</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak Ada
<input type="checkbox"> Ya
</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3">
<table border="1">
<tr valign="top" align="center">
<td>Jenis Penyebab Alergi </td>
<td>Reaksi yang timbul</td>
</tr>
<tr>
<td> <br> <br> <br></td>
<td> <br> <br> <br></td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>12.</td>
<td>Kebiasaan</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>a) Merokok</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, Jumlah ..............................
</td>
</tr>
<tr valign="top">
<td> </td>
<td>b) Kopi</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, Jumlah ..............................
</td>
</tr>
<tr valign="top">
<td> </td>
<td>c) Alkohol</td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, Jumlah ..............................
</td>
</tr>
<tr valign="top">
<td> </td>
<td>d) Obat </td>
<td>:</td>
<td>
<input type="checkbox"> Tidak
<input type="checkbox"> Ya, <i>(tuliskan nama obat)</i> ..............................
</td>
</tr>
</table>
<p style="page-break-before: always;"> </p>
<table border="1">
<tr valign="top">
<td width="50%" align="center">
<center><b>INFORMASI MEDIK</b></center>
</td>
<td width="50%" align="center">
<center><b>KEADAAN UMUM SAAT INI</b></center>
</td>
</tr>
<tr valign="top">
<td>
<table border="0">
<tr valign="top">
<td width="39%">a. Menarche</td>
<td width="1%">:</td>
<td width="60%">..............................Thn</td>
</tr>
<tr valign="top">
<td>b. Lamanya</td>
<td>:</td>
<td>..............................Hr</td>
</tr>
<tr valign="top">
<td>c. Siklus Haid</td>
<td>:</td>
<td>
<input type="checkbox"> Teratur <br>
<input type="checkbox"> Tidak Teratur
</td>
</tr>
<tr valign="top">
<td>d. Lama Haid</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr valign="top">
<td>e. Dysmenorhoe</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr valign="top">
<td>f. Pernikahan ke</td>
<td>:</td>
<td>
Istri : ..............................<br>
Suami : ..............................
</td>
</tr>
<tr valign="top">
<td>g. Usia Perkawinan</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr valign="top">
<td>h. Jenis kontrasepsi yang digunakan</td>
<td>:</td>
<td>..............................</td>
</tr>
<tr valign="top">
<td>i. Terakhir Kontrasepsi </td>
<td>:</td>
<td>
thn : ..............................<br>
bln : ..............................
</td>
</tr>
<tr valign="top">
<td>j. Riwayat Intervility </td>
<td>:</td>
<td>
Primer : ..............................<br>
Sekunder : ..............................
</td>
</tr>
<tr valign="top">
<td colspan="3">k. Riwayat kehamilan dan persalinan<br>
<table border="1">
<tr valign="top" align="center">
<td rowspan="2">No</td>
<td rowspan="2">L/P</td>
<td colspan="2">Umur</td>
<td rowspan="2">Jenis<br>Persalinan</td>
<td rowspan="2">BBL<br>Gram</td>
<td rowspan="2">Penolong</td>
<td rowspan="2">Tempat<br>Lahir</td>
<td colspan="2">Kondisi Umum</td>
</tr>
<tr>
<td>Anak</td>
<td>Kehamilan</td>
<td>Ibu</td>
<td>Bayi</td>
</tr>
<tr>
<td>1.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>2.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>3.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>4.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>5.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>6.</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>l. Riwayat kehamilan saat ini</td>
<td colspan="2">:</td>
</tr>
<tr valign="top">
<td colspan="3">
<table border="1">
<tr valign="top">
<td>- HPHT : ......../.........../...........</td>
</tr>
<tr valign="top">
<td>- Tafsiran Putus : ......../.........../...........</td>
</tr>
<tr valign="top">
<td>- Apakah kehamilan ini direncanakan/diinginkan :
<input type="checkbox"> Ya
<input type="checkbox"> Tidak
</td>
</tr>
<tr valign="top">
<td>- Jenis kelamin yang diharapkan :
<input type="checkbox"> Laki-laki
<input type="checkbox"> Perempuan
</td>
</tr>
</table>
</td>
</tr>
<tr valign="top">
<td>m. Keluhan saat hamil</td>
<td colspan="2">:</td>
</tr>
<tr valign="top">
<td colspan="3">
<table border="1">
<tr valign="top">
<td>- Mual :
<input type="checkbox"> Tidak
<input type="checkbox"> Ya,Sejak...............</td>
</tr>
<tr>
<td>- Muntah :
<input type="checkbox"> Tidak
<input type="checkbox"> Ya,Frekuensi...............x/hari</td>
</tr>
<tr>
<td>- Pendarah pervaginam : <br>
<input type="checkbox"> Tidak <br>
<input type="checkbox"> Ya,kapan...............x/hari<br>
Banyaknya...............x/hari</td>
</tr>
<tr valign="top">
<td>- ANC kehamilan saat ini :
Di ...............
Dokter...............</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td>
<table border="0">
<tr valign="top">
<td width="39%">Status Obstetr</td>
<td width="1%">:</td>
<td width="60%"> G............ P........... A.......</td>
</tr>
<tr valign="top">
<td>Keadaan Umum</td>
<td>:</td>
<td>
<input type="checkbox"> Baik
<input type="checkbox"> Sedang
<input type="checkbox"> Buruk
</td>
</tr>
<tr valign="top">
<td colspan="3"><center><b>NUTRISI</b></center></td>
</tr>
<tr valign="top">
<td colspan="3" align="center">LILA : ............... BB : ............... TB : ...............</td>
</tr>
<tr valign="top">
<td colspan="3">
<table border="1">
<tr valign="top" align="center">
<td>KATEGORI</td>
<td>0</td>
<td>0</td>
<td>2</td>
<td>SKOR</td>
</tr>
<tr valign="top">
<td>Kehilangan BB dalam 6 bulan</td>
<td>Tidak Ada</td>
<td>Ada .... kg</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>Asupan makanan 5 hari terakhir</td>
<td>Tidak Berubah</td>
<td>Habis >1/2 porsi</td>
<td>Habis >1/2 porsi</td>
<td> </td>
</tr>
<tr valign="top">
<td>Gangguan saluran cerna persisten 2 minggu</td>
<td>Tidak Gangguan</td>
<td>Mual, disfagia, Anoreksia</td>
<td>Muntah, Diare</td>
<td> </td>
</tr>
<tr valign="top">
<td>Aktivitas Harian</td>
<td>Normal</td>
<td>Dibantu</td>
<td>Tirah baring</td>
<td> </td>
</tr>
<tr valign="top">
<td colspan="4"> Skor Total</td>
<td> </td>
</tr>
</table><br>
Penyakit/gangguan penyerta saat ini :
<input type="checkbox"> Tidak
<input type="checkbox"> Ya <br>
<table border="1">
<tr valign="top" align="left">
<td><input type="checkbox"> 1 DM </td>
<td><input type="checkbox"> 2 Stroke</td>
</tr>
<tr valign="top" align="left">
<td><input type="checkbox"> 1 Asam Urat </td>
<td><input type="checkbox"> 2 Kanker</td>
</tr>
<tr valign="top" align="left">
<td><input type="checkbox"> 1 Hipertensi </td>
<td><input type="checkbox"> 2 Gangguan Hati</td>
</tr>
<tr valign="top" align="left">
<td><input type="checkbox"> 1 Dislipidemia </td>
<td><input type="checkbox"> 2 Gangguan Ginjal</td>
</tr>
<tr valign="top" align="left">
<td><input type="checkbox"> 1 Maag/gastritis </td>
<td><input type="checkbox"> 2 OP saluran cerna</td>
</tr>
</table><br>
Skor : .............................................<br>
Skor nutrisi dijumlah dengan skor penyakit/gangguan :<br>
<input type="checkbox"> Bila 0-2 asesment oleh perawat/bidan <br>
<input type="checkbox"> Bila >2 asesment diinfokan ke ahli gizi <br>
untuk penatalaksanaan lebih lanjut<br>
<center><b>AKTIVITAS</b></center><br>
<table border="1">
<tr>
<td colspan="4">A.Kemampuan melakukan aktivitas</td>
</tr>
<tr valign="top" align="left">
<td width="40%">Mandiri</td>
<td width="10%"><input type="checkbox"></td>
<td width="40%">Bantuan Sebagian</td>
<td width="10%"><input type="checkbox"></td>
</tr>
<tr valign="top" align="left">
<td>Bantuan Minimal</td>
<td><input type="checkbox"></td>
<td>Bantuan Total</td>
<td><input type="checkbox"></td>
</tr>
<tr align="center">
<td colspan="4">B.Berjalan</td>
</tr>
<tr valign="top" align="left">
<td>TAK</td>
<td><input type="checkbox"></td>
<td>Deformitas</td>
<td><input type="checkbox"></td>
</tr>
<tr valign="top" align="left">
<td>Sering Jatuh</td>
<td><input type="checkbox"></td>
<td>Hilang Keseimbangan</td>
<td><input type="checkbox"></td>
</tr>
<tr valign="top" align="left">
<td>Penurunan Kekuatan/ROM</td>
<td><input type="checkbox"></td>
<td>Riwayat patah tulang</td>
<td><input type="checkbox"></td>
</tr>
<tr valign="top" align="left">
<td>Paralysis</td>
<td><input type="checkbox"></td>
<td> </td>
<td> </td>
</tr>
<tr align="center">
<td colspan="4">C.Alat Ambulasi</td>
</tr>
<tr align="center">
<td colspan="4">
<input type="checkbox"> Walker
<input type="checkbox"> Tongkat
<input type="checkbox"> Kursi roda <br>
</td>
</tr>
</table><br>
Keterangan : <br>
- Kriteria Mandiri dipoint A dan TAK di B tidak Termasuk kriteria penilaian<br>
- Bila ada kriteria point A,B,C di setiap kajian dilaporkan ke DPJP<br>
- Kalau ada pasien memakai alat ambulasi dilaporkan ke DPJP<br>
</td>
</tr>
</table>
</td>
</tr>
</table>
<p style="page-break-before: always;"> </p>
<table border="1">
<tr valign="top">
<td width="50%" align="center">
<center><b>PROTEKSI</b></center>
</td>
<td width="50%" align="center">
<center><b>KENYAMANAN</b></center>
</td>
</tr>
<tr valign="top">
<td>
<table border="0">
<tr valign="top">
<td width="5%">A.</td>
<td width="35%">Status Mental :</td>
<td width="30%"><input type="checkbox"> Orientasi</td>
<td width="30%"><input type="checkbox"> Agitasi</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Menyerang</td>
<td><input type="checkbox"> Kooperatif</td>
<td><input type="checkbox"> Letargi</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Disorientasi</td>
<td><input type="radio"> Orang<br>
<input type="radio"> Waktu</td>
<td><input type="radio"> Tempat</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Kejang</td>
<td><input type="radio"> Tidak</td>
<td><input type="radio"> Ya</td>
</tr>
<tr valign="top">
<td> </td>
<td>Tipe :</td>
<td>................</td>
<td>Frekuensi :........</td>
</tr>
<tr valign="top">
<td>B.</td>
<td>Status psikologis :</td>
<td><input type="checkbox"> Tenang</td>
<td ><input type="checkbox"> Hiperaktif</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Mengganggu sekitar</td>
<td><input type="checkbox"> Cemas</td>
<td><input type="checkbox"> Sedih</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Marah</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>C.</td>
<td>Adakah alasan penggunaan restrain Sebelumnya:</td>
<td><input type="checkbox"> Ya Alasannya : <br>
<input type="radio"> Membahayakan diri sendiri <br>
<input type="radio"> Membahayakan orang lain
</td>
<td><input type="checkbox"> Tidak</td>
</tr>
<tr valign="top">
<td>D.</td>
<td colspan="3">Pengkajian Resiko Jatuh <br>
<table border="1">
<tr valign="top" align="left">
<td width="25%">Parameter</td>
<td width="45%">Compos Mentis </td>
<td width="15%">Skor</td>
<td width="15%">Nilai</td>
</tr>
<tr valign="top">
<td rowspan="3">Tingkat Kesadaran </td>
<td>Compos mentis</td>
<td>0</td>
<td rowspan="3"> </td>
</tr>
<tr>
<td>Somnolen</td>
<td>1</td>
</tr>
<tr>
<td>Gelisah, orientasi, apatis</td>
<td>2</td>
</tr>
<tr valign="top">
<td rowspan="3"> </td>
<td>Tidak pernah jatuh dalam 3 bulan ini</td>
<td>0</td>
<td rowspan="3"> </td>
</tr>
<tr>
<td>Pernah jatuh 1x dalam 3 bulan ini</td>
<td>1</td>
</tr>
<tr>
<td>Pernah >1x dalam 3 bulan ini</td>
<td>2</td>
</tr>
<tr valign="top">
<td rowspan="3"> </td>
<td>Eliminasi ke kamar mandi, kateter,pampers, pispot urinal</td>
<td>0</td>
<td rowspan="3"> </td>
</tr>
<tr>
<td>Eliminasi dengan menggunakan cemmode</td>
<td>1</td>
</tr>
<tr>
<td>Eliminasi ke kamar mandi dengan bantuan</td>
<td>2</td>
</tr>
<tr valign="top">
<td rowspan="3"> </td>
<td>Penglihatan normal</td>
<td>0</td>
<td rowspan="3"> </td>
</tr>
<tr>
<td>Menggunakan kacamata</td>
<td>1</td>
</tr>
<tr>
<td>Masih terdapat gangguan walaupun menggunakan kacamata</td>
<td>2</td>
</tr>
<tr valign="top">
<td rowspan="4"> </td>
<td>Saat ini tidak menggunakan obat-obatan 7 hari terakhir</td>
<td>0</td>
<td rowspan="4"> </td>
</tr>
<tr>
<td>Adanya perubahan obat/dosis pada 5 hari terakhir</td>
<td>1</td>
</tr>
<tr>
<td>Saat ini menggunakan 1-2 obat/7 hari terakhir</td>
<td>2</td>
</tr>
<tr>
<td>Saat ini menggunakan 3-4 obat/7 hari terakhir</td>
<td>3</td>
</tr>
<tr valign="top">
<td rowspan="3"> </td>
<td>Tidak ada penyakit penyerta</td>
<td>0</td>
<td rowspan="3"> </td>
</tr>
<tr>
<td>1-2 penyakit penyerta > penyakit penyerta</td>
<td>1</td>
</tr>
<tr>
<td>>3 penyakit penyerta</td>
<td>2</td>
</tr>
<tr>
<td colspan="2" align="center">TOTAL SKOR</td>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="2" align="center">Nama dan Tanda Tangan Perawat </td>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="2"> </td>
<td colspan="2"> </td>
</tr>
</table><br>
Kategori : <br>
Skor 1 : Lakukan intervensi keperawatan beresiko jatuh<br>
Skor 2 : Lakukan penilaian ulang 3 hari lagi/jika kondisi berubah/ postoperasi, minum obat/transfer unit/ post jatuh saat di RS
</td>
</tr>
</table>
</td>
<td>
Adakah rasa nyeri : <input type="checkbox"> Tidak <input type="checkbox"> Ya, Skor .......<br>
<img src="wajah.PNG" width="100%"><br>
<table border="0">
<tr valign="top">
<td width="5%"> </td>
<td width="35%">Tipe :</td>
<td width="30%"><input type="checkbox"> Akut</td>
<td width="30%"><input type="checkbox"> Kronis</td>
</tr>
<tr valign="top">
<td> </td>
<td>Lokasi :</td>
<td>.................. </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>Frekuensi :</td>
<td><input type="checkbox"> Jarang<br>
<input type="checkbox"> Terus menerus</td>
<td><input type="checkbox"> Hilang timbul</td>
</tr>
<tr valign="top">
<td> </td>
<td>Lama nyeri :</td>
<td>.................. </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>Nyeri mempengaruhi :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tidur</td>
<td><input type="checkbox"> Aktivitas fisik </td>
<td><input type="checkbox"> Emosi </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Konsentrasi</td>
<td><input type="checkbox"> Nafsu makan</td>
<td><input type="checkbox"> ................</td>
</tr>
<tr valign="top">
<td colspan="4">II. PEMERIKSAAN FISIK </td>
</tr>
<tr valign="top">
<td>1.</td>
<td>TTV : ...............</td>
<td>TD : ...............mmHg</td>
<td>Suhu : ...............C</td>
</tr>
<tr valign="top">
<td> </td>
<td>Nadi : ...............x/mnt</td>
<td>RR : ...............x/mnt</td>
<td>SaO2 : ...............%</td>
</tr>
<tr valign="top">
<td>2.</td>
<td>Kesadaran :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>a. Kuantitatif : </td>
<td>GCS : ...............</td>
<td>E : ...............</td>
</tr>
<tr valign="top">
<td> </td>
<td> </td>
<td>M : ...............</td>
<td>V : ...............</td>
</tr>
<tr valign="top">
<td> </td>
<td>b. <input type="checkbox"> CM</td>
<td><input type="checkbox"> Apatis</td>
<td><input type="checkbox"> Delirium</td>
</tr>
<tr valign="top">
<td> </td>
<td> <input type="checkbox"> Somnolen</td>
<td><input type="checkbox"> Sopor</td>
<td><input type="checkbox"> Korma</td>
</tr>
<tr valign="top">
<td>3.</td>
<td>Kepala :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Asimetris</td>
<td><input type="checkbox"> Hematoma</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Nyeri kepala :</td>
<td><input type="radio"> Ya</td>
<td><input type="radio"> Tidak</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"><input type="checkbox"> Jika Ya, lanjutkan ke pengkajian nyeri</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> ............</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>4.</td>
<td>Rambut :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Kotor</td>
<td><input type="checkbox"> Rontok</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"><input type="checkbox"> Berminyak ............</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> ............</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>5.</td>
<td>Wajah :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Asimetris</td>
<td><input type="checkbox"> Bellspaalsy</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Moon face</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>6.</td>
<td>Mata :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Kabur</td>
<td><input type="checkbox"> Nyeri</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Konjungtiva anemis</td>
<td><input type="checkbox"> Sklera ikterik </td>
<td><input type="checkbox"> Strabismus</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Buta</td>
<td><input type="checkbox"> ................ </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Pupil :</td>
<td><input type="radio"> Isokor </td>
<td><input type="radio"> Anisokor </td>
</tr>
<tr valign="top">
<td> </td>
<td> </td>
<td><input type="radio"> Miosis </td>
<td><input type="radio"> Isokor </td>
</tr>
<tr valign="top">
<td> </td>
<td> </td>
<td><input type="radio"> Pinpoin </td>
<td> </td>
</tr>
<tr valign="top">
<td>7.</td>
<td>Telinga :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Keluar Cairan</td>
<td><input type="checkbox"> Tuli</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Berdengung</td>
<td colspan="2"><input type="checkbox"> Pendengaran kurang </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Nyeri</td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
<tr valign="top">
<td>8.</td>
<td>Hidung :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Asimetris</td>
<td><input type="checkbox"> Polip</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Epistaksis</td>
<td colspan="2"><input type="checkbox"> Keluar Cairan </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Terpasang</td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
</table>
</td>
</tr>
</table>
<p style="page-break-before: always;"> </p>
<table border="1">
<tr valign="top">
<td width="50%" align="center">
<center><b>PROTEKSI</b></center>
</td>
<td width="50%" align="center">
<center><b>KENYAMANAN</b></center>
</td>
</tr>
<tr valign="top">
<td width="50%">
<table border="0">
<tr valign="top">
<td width="5%">9.</td>
<td width="40%">Mulut :</td>
<td width="30%"> </td>
<td width="25%"> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Asimetris</td>
<td><input type="checkbox"> Bibir Pucat </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Mukosa kering</td>
<td colspan="2"><input type="checkbox"> ................... </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Terpasang ...................</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>10.</td>
<td>Gigi :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Karies</td>
<td><input type="checkbox"> Goyang </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Berlubang</td>
<td><input type="checkbox"> Gigi palsu </td>
<td><input type="checkbox"> ................... </td>
</tr>
<tr valign="top">
<td>11.</td>
<td>Lidah :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Kotor</td>
<td><input type="checkbox"> Stomatitis </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Gerakan asimetris</td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
<tr valign="top">
<td>12.</td>
<td>Tenggorokan :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Tonsil membesar</td>
<td><input type="checkbox"> Faring merah </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Sakit menelan </td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
<tr valign="top">
<td>13.</td>
<td>Leher :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Pembesaran tiroid</td>
<td><input type="checkbox"> Kaku kuduk </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Pembesaran vena jugularis </td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
<tr valign="top">
<td>14.</td>
<td>Dada :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Asimetris</td>
<td><input type="checkbox"> Retraksi </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Nyeri dada :</td>
<td><input type="radio"> Ya</td>
<td><input type="radio"> Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3">Jika Ya, lanjutkan ke pengkajian nyeri ...................</td>
</tr>
<tr valign="top">
<td>15.</td>
<td>Paru-paru :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Wheezing</td>
<td><input type="checkbox"> Ronchi </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Dispnea </td>
<td><input type="checkbox"> ................... </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Batuk :</td>
<td><input type="radio"> Ya</td>
<td><input type="radio"> Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Sputum :</td>
<td><input type="radio"> Ya</td>
<td><input type="radio"> Tidak </td>
</tr>
<tr valign="top">
<td>16.</td>
<td>Jantung :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Bradikardi</td>
<td><input type="checkbox"> Takikardi </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Palpitasi</td>
<td><input type="checkbox"> Aritmia</td>
<td><input type="checkbox"> ................... </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Sirkulasi :</td>
<td><input type="radio"> Akral hangat</td>
<td><input type="radio"> Akral dingin </td>
</tr>
<tr valign="top">
<td>17.</td>
<td>Payudara :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>a. Bentuk payudara :</td>
<td colspan="2"><input type="radio"> Simetris <input type="radio">Asimetris</td>
</tr>
<tr valign="top">
<td> </td>
<td>b. Bentuk Putting :</td>
<td colspan="2"><input type="radio"> Datar <input type="radio">Menonjol </td>
</tr>
<tr valign="top">
<td> </td>
<td>c. Benjolan/tumor :</td>
<td colspan="2"><input type="radio"> Ada <input type="radio">Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td> Pengeluaran Asi/Kolostrum : </td>
<td colspan="2"><input type="radio"> Ada <input type="radio">Belum ada ............. </td>
</tr>
<tr valign="top">
<td>18.</td>
<td>Posisi Tulang belakang :</td>
<td colspan="2"><input type="radio"> Normal <input type="radio">Skoliosis </td>
</tr>
<tr valign="top">
<td> </td>
<td>Nyeri ketuk pada pinggang : </td>
<td colspan="2"><input type="radio"> Ya <input type="radio">Tidak </td>
</tr>
<tr valign="top">
<td>19.</td>
<td>Abdomen</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>a. Inspeksi</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Pembesaran : sesuai usia kehamilan<br> <input type="radio"> Ya <input type="radio">Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Striae gravidarum :<br> <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Linea nigra : <br> <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Bekas luka operasi : <br> <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
</table>
</td>
<td>
<table border="0">
<tr valign="top">
<td> </td>
<td>b. Palpasi</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Bentuk : Memanjang melintang tinggi fundus uteri : ............ Cm<br> (Usia Kehamilan >24 minggu)</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Kontraksi : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> leopold I : <br> <input type="radio"> Kepala <input type="radio">Bokong <input type="radio">Kosong</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Leopold II : <br> <input type="radio"> Punggung kaki <input type="radio">Bagian kecil <input type="radio">Kepala</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Leopold III : <br> <input type="radio"> Kepala <input type="radio">Bokong <input type="radio">Kosong</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Penurunan Kepala <br> <input type="radio"> Sudah <input type="radio">Belum</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> leopold IV :</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Bagian masuk PAP :<br> <input type="radio"> 1/5 <input type="radio">2/5 <input type="radio">3/5 <input type="radio">4/5 <input type="radio">5/5</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Taksiran berat janin : ............ gram</td>
</tr>
<tr valign="top">
<td> </td>
<td>c. Auskultasi</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Denyut jantung janin : ............ x/mnt</td>
</tr>
<tr valign="top">
<td> </td>
<td>d. His</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Hasil CTG, Frekuensi : ............ x/mnt</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> <input type="checkbox"> Teratur <input type="checkbox">Tidak teratur</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Kekuatan his : <br> <input type="checkbox"> Ringan <input type="checkbox">Sedang <input type="checkbox">Berat<br><i>Lanjutkan pada form partograf </i></td>
</tr>
<tr valign="top">
<td>20.</td>
<td>Anogenital</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>a. Inspeksi</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Perineum luka parut : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Vula vagina : <input type="radio"> Merah muda <input type="radio">Merah</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Luka : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Pengeluaran per vagina : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Pembengkakan : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Rasa Nyeri : <input type="radio"> Ada <input type="radio">Tidak Ada</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Anus : Heamoroid <input type="radio"> Ada <input type="radio">Tidak Ada<br><i> Periksa dalam servik dan vagina </i></td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> (Jika ada indikasi) : <br> <input type="radio"> Tidak dilakukan <input type="radio">Ya, - Vulva/ vagina</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Portio :
<input type="radio"> Tipis <input type="radio">Tebal
<input type="radio"> Lunak <input type="radio">Kaku
</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Ketuban : <input type="radio"> Utuh <input type="radio">Negatif</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Pembukaan : .................. cm</td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3"> Penurunan bagian terendah : <br>
<input type="radio"> Hodge I <input type="radio">Hodge II<br>
<input type="radio"> Hodge III <input type="radio">Hodge IV
</td>
</tr>
<tr valign="top">
<td>21.</td>
<td>Ekstremitas atas dan bawah :</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td>Inspeksi : Edema : </td>
<td><input type="checkbox"> Ya</td>
<td><input type="checkbox"> Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td>Palpasi : Varises : </td>
<td><input type="checkbox"> Ya</td>
<td><input type="checkbox"> Tidak </td>
</tr>
<tr valign="top">
<td> </td>
<td colspan="3">Reflek patella : + / - (jika ada)</td>
</tr>
<tr valign="top">
<td>22.</td>
<td>Eliminasi :<br>a. BAB</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Konstipasi</td>
<td><input type="checkbox"> ................... </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Diare</td>
<td colspan="2"><input type="checkbox"> ...................x/hari </td>
</tr>
<tr valign="top">
<td> </td>
<td>b. BAK</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> Tak</td>
<td><input type="checkbox"> Oligurai</td>
<td><input type="checkbox"> Poliuri</td>
</tr>
<tr valign="top">
<td> </td>
<td><input type="checkbox"> ................... </td>
<td> </td>
<td> </td>
</tr>
</table>
</td>
</tr>
</table>
<p style="page-break-before: always;"> </p>
<table border="1">
<tr valign="top">
<td width="50%" align="center">
<center><b>PROTEKSI</b></center>
</td>
<td width="50%" align="center">
<center><b>KENYAMANAN</b></center>
</td>
</tr>
<tr valign="top">
<td width="50%">
<table border="0">
<tr valign="top">
<td>23.</td>
<td colspan="3">Pemeriksaan Penunjang :<br>
........................................................<br>
........................................................<br>
........................................................<br>
</td>
</tr>
<tr valign="top">
<td>24.</td>
<td colspan="3">Perenanaan Perawatan Lanjutan :<br>
........................................................<br>
........................................................<br>
........................................................<br>
</td>
</tr>
</table><br>
</td>
<td>
<center><b>III. DIAGNOSA / MASALAH POTENSIAL</b><br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br></center>
<center><b>IV. KEBURUHAN TINDAKAN SEGERA</b><br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br></center>
<center><b>V. PELAKSANAAN</b><br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br>
........................................................<br></center>
<br><br><br>
<table border="0">
<tr valign="top">
<td> </td>
<td>Tanggal </td>
<td>:</td>
<td> ...................</td>
</tr>
<tr valign="top">
<td> </td>
<td>Jam </td>
<td>:</td>
<td> ...................</td>
</tr>
</table>
<br><br><br>
<table border="0">
<tr valign="top" align="center">
<td> </td>
<td>Perawat I</td>
<td> </td>
<td>Perawat II</td>
</tr>
<tr valign="top" align="center">
<td> </td>
<td><br> <br> <br> <br> <br> (...................)</td>
<td> </td>
<td><br> <br> <br> <br> <br> (...................)</td>
</tr>
</table>
</td>
</tr>
</table>
</body>
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