rsi siti khodijah

8/19/2019 Rsi Siti Khodijah

http://slidepdf.com/reader/full/rsi-siti-khodijah 1/6



RSI SITI KHODIJAH

CATATAN PERKEMBANGAN

SUHAN KEBIDANAN

Nama : No. RM :

Umur : L/P Ruang / Kelas :

Tgl.

&am'u#$ekti( )#$ekti( Assesment &am Planning Para(

* + , - 0

Tgl.

&am

'u#$ekti( )#$ekti( Assesment &am Planning Para(

* + , - 0



RSI SITI KHODIJAH

KEPERAATAN

RINGKASAN ! KELUAR

Nama : No. RM :


Doktor yang merawat : Tanggal Mauk :1idan / Perawat 2rimer : Tanggal 2engka$ian :3ara masuk : 4R& 45D Doktor 2ri#adi Langsung kamar #ersalin

A" DATA SUB#EKTI$

%" Ke&'an

'tama ....................................................................................................................................................................................................................................................................................

*" R+wayat Men,tr'a,+Umur menarr6he : ................... th7 lamanya haid ................ hari7 $umlah daerah haid ..................8aid terakhir : .................................................................. Perkiraan 2artus ............................ Dismonerroe9 s2oting9 menorragia metrorhagia9 2er menstruasi sindrome-

." R+wayat Perkaw+nan'tatus 2erkawinan : ................................7 Kawin ...................... KaliKawin / umum : ................................. Th7 dengan suami 4 ............... th7 ke 44 ............ th

/" Riwayat Kehamilan7 dan Ni(as yang lalu5 ...................... P ................... A .................... 8idu2

N

o

Tgl. Tahun

Partus

Tempat

Partus

Umur

Hamil

Jenis

Persalinan

Penolong

PersalinanPenyulit Nufas

AnakKet / BB

Keadaan

Anak Sek

!

"

#

$

0" R+wayat Ham+& +n+8amil Muda : Mual Muntah Perdarahan Lain lian .................8amil Tua : Pusing 'akit ke2ala Perdarahan Lain lian .................

1" R+wayat Penyak+t yang &a&' 2 P3ra,+

; Pernah dieawat : .........................................7 Ka2an .....................7 Dimana ...........................

; Pernah dio2rasi : .........................................7 Ka2an .....................7 Dimana ...........................

4" R+wayat Penyak+t Ke&'arga5 ( Aya5 I6'5 A7+k5 Paman5 B+6+ ) yang 3erna men7er+ta ,ak+t Kanker Penyakit 8ati 8i2ertensi DM Penyakit 5in$al Penyakit

Kelainan 1awaan 8amil T13 <2ile2si Alergi

8" R+wayat Gyneko&og+ 4n(ertilitas 4n(eksi =irus PM' 3er=isitensi <ndometerosis Myoma Poli2 ser=i> Kanker kandungan )2rasi Kandungan Perkosaan

9" R+wayat Ke&'arga Beren:anaMetode K1 yang 2ernah di2akai ............................ Lama ..................................................................Kom2likasi K1 Perdarahan P4D / Radang 2aanggul

RSI SITI KHODIJAH

KEPERAATAN

RINGKASAN ! KELUAR

Nama : No. RM :


%;" Riwayat Ke#iasaan Makan / Minum / PesikosialPola makan sehari ..............7 kali9 minum : Alkohol )#at;o#atan / &amu Ko2i'osial su22ort : 'uami )rang tua Mertua Keluarga lain

B" DATA <B#EKTI$%" Pemer+k,aan $+,+k

Pemeriksaan umum : .................... Kesadaran .............. 1erat #adan ............ Tinggi #adan ............Tekanan darah : ...............mm8g : Nadi ........... >/mnt. 'uhu ........... Perna(asan ...........mm8g

+. Pemeriksaan isik



Mata Pandangan ka#ur Adanya 2andangan dua'klera in6teri6 3on$ungti=a 2u6at

Dada dan A>ylia Mammae symentris / asimentris Areola hi2er2igmentasiPuting susu menon$ol Tumor Kolostrum !?"

<kstremitas Tungkai simetris / asimentris <dema ?/; Re(le> 2atella ?/;'istem Kardio Dys2neu )rtho2neu Tha6y2neu @heeing 1atuk

'2utum 1atuk darah nyeri dada Keringat malam,. Pemer+k,aan k',', 7an n+=a,

a. )#setetri6 A#domen

4ns2eksi : Mem#esar dengan arah meman$ang Mele#ar Pele#aran =ena Line al#aLinea ni(gra 'triae li=ide striaeal#i6an Luka #ekas o2rasi Lain;lain

Pla2asi TU .................. 6m let 2unggung9 Puka / 2uki / .........................................................................Nyeri tekan9 )#s#on test 3ekung 2ada 2erut

Taksiran #erat $anin ................................. gram ....................................................................................... Auskultasi : D&& .............................. /menit Teratur tidak teratur 8is tia2 : ..................................... /menit Teratur tidak teratur

#. 5ynekologi Ano genital :4s2eksi : Pengeluaran 2er =ul=a : Darah Lendir Air Ketu#an4ns2ekulo : Bagina ....................................... Portio ..........................................................Bagina toou6her : .........................................................................................................................4m#ang (eto 2el=ik : .........................................................................................................................

6. Ni(asU ...........................7 3ountraksi ut : .................................................... Lo6hea ......................................Luka $alan lahir .........................................................................................................................................

-. Pemeriksaan Penun$angDarah 8#7 ................... AL ....................... 3T ......................... 1T .....................7 Urine 2rotein .........................5ol darah ...............................................................................7 U'5 ....................................................................

. Diagnosa Masalah Ke#idanan..............................................................................................................................................................................

............................................................................................................................................................................... Resiko Diagnosa dan masalah ke#idanan

..............................................................................................................................................................................

..............................................................................................................................................................................

0. Peren6anaan dan Ke#utuhan..............................................................................................................................................................................

..............................................................................................................................................................................

Pal2asi : .....................................................................................................................................................................

Aus6ultasi : .....................................................................................................................................................................

P<R48AL 1<R'AL4N

Tgl 3atatan $alannya 2ersalinan Tgl 3atatan &alannya 2ersalinan



&enis Anak : .............................. Pla6enta : ........................................ Pendarahan : Kala 44 : ........................66L. Ke2 : .........................6m 1erat : ....................................gr Kala 444 : ........................66L. dada : .........................6m 2.t 2usat : ...................................6m Kala 4B : ........................66

: .........................6m 4nsertio : ........................................ Tensi 2.2 : ..............................................: .........................kg Te#al : ...................................6m Tensi 2.2 : ..............................................

rsi siti khodijah

Documents