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Культура Документы
B. DATA SUBJEKTIF
1. Alasan datang ke RS
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2. Keluhan utama
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3. Riwayat Obstetri
Riwayat Kehamilan Sekarang : G.................P................A...............
3.1.1. HPHT : ............................................................................
3.1.2. Gerakan janin : ............................................................................
3.1.3 Keluhan saat hamil muda :..........................................................................
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3.1.4. PNC : ............................................................................
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3.1.5. Imunisasi TT : ............................................................................
3.1.6. Obat yang dikonsumsi : Obat (................................................................)
Jamu (................................................................)
Riwayat Haid
3.2.1. Menarche : …………………………………………
3.2.2. Siklus : …………………………………………
3.2.3. Lamanya : …………………………………………
3.2.4. Banyaknya : …………………………………………
3.3.5. Desmenorhoe : …………………………………………
4. Riwayat Ginekologi
4.1. Infertilitas: ....................................................................................................
4.2. Masa : ....................................................................................................
4.3. Penyakit : ....................................................................................................
4.4. Operasi : ....................................................................................................
5. Riwayat KB
5.1. Kontrasepsi yang dipakai: ............................................................................
5.2. Keluhan : ……………………………………………........
5.3. Kontrasepsi yang lalu : …………………………………………............
5.4. Lamanya pemakaian : ……………………………………………........
5.5. Alasan berhenti : ............................................................................
C. DATA OBJEKTIF
1. Kesadaran
(__) Komposmentis
(__) Somnolent
(__) Sopor
(__) Sopor komatus
(__) Komatus
2. Tanda-tanda Vital
Nadi ……………X/mnt
Suhu …………...X/mnt
Tensi …………..mmHg
Respirasi ……….X/mnt
3. Kepala
Rambut : …………………………………………………………………
Mata : Konjungtiva : …………………………………………………
Sclera :
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Pengelihatan : …………………………………………………
Telinga: …………………………………………………………………
Hidung : …………………………………………………………………
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Mulut : …………………………………………………………………
Leher : …………………………………………………………………
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4. Thorax
Dada : Bentuk simetri : Ya (__) Tidak (__)
Mamae : Bentuk simetris : Ya (__) Tidak (__)
Puting Susu : ………………………………………....
Benjolan : …………………………………………
Ekskresi : …………………………………………
Paru-paru : …………………………………………………………………
Jantung : …………………………………………………………………
5. Abdomen
Inspeksi : Bentuk : …………………………………………………
Striae : ……………………………………....................
Bekas luka Operasi : ………………………………..................
Palpasi : Tinggi Fundus Uteri : ………… …Cm
Lingkar Perut : .................... Cm
Posisi Janin : Leopold I : ……………………………………...
Leopold II : ……………………………………..
Leopold III :
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Leopold IV : ……………………………………
Kontraksi Uterus : frekuensi :……………………………….
Interval :
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Intensitas : ………………………………
Auskultasi DJJ : .............................................................................................
Bising usus :…………………………………………………….
6. Genetalia Luar
Bentuk : …………………………………………………………………
Varices: …………………………………………………………………
Oedema : …………………………………………………………………
Massa / Kista : ....................................................................................................
Pengeluaran pervigam : .......................................................................................
7. Pemeriksaan dalam
Vulva / vagina : ....................................................................................................
Portio : ....................................................................................................
Pembukaan : ....................................................................................................
Ketuban : ....................................................................................................
Presentasi : ....................................................................................................
Penurunan Kepala (5/5): ......................................................................................
8. Ekstremitas (tangan & kaki)
Bentuk : Kaki : ................................. Tangan : .......................................
Kuku : Kaki : ................................ Tangan : .......................................
Refleks Patela : ................................
Oedema : ................................
9. Kulit
Warna : ....................................
Turgor : ....................................
E. PERENCANAAN
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F. PENATALAKSANAAN
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G. EVALUASI
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