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KEMENTRIAN KESEHATAN R.

I
POLITEKNIK KESEHATAN
PALANGKARAYA
Jl. G. Obos No. 32 Palangkaraya. Telp/Fax : (0536) 21768, 35146, 37504
E-mail : poltekkes_kalteng@telkom.net

NAMA MAHASISWA
NIM
TEMPAT PRAKTEK
TANGGAL PRAKTEK

: MARIATI
: PO.62.24.2.10.101
: ...........................................................
: ...........................................................

FORMAT PENGKAJIAN PADA IBU HAMIL


A. IDENTITAS
Nama Ibu
: ....................................
Umur
: ....................................
Suku/bangsa : ....................................
Agama
: ....................................
Pendidikan
: ....................................
Pekerjaan
: ....................................
Alamat rumah : ....................................
Telepon
: ....................................

Nama Suami : ......................................


Umur
: ......................................
Suku/bangsa : ......................................
Agama
: ......................................
Pendidikan
: ......................................
Pekerjaan
: ......................................
Alamat Rumah : ......................................
Telepon
: ......................................

B. ANAMNESA
Pada Tanggal
: .....................................
Pukul : ...............................
1. Kunjungan yang ke
: .................................
2. Alasan kunjungan
: ........................................................................................................
Keluhan utama
: .........................................................................................................
.........................................................................................................
.........................................................................................................
3. Riwayat psikososial
a. Kehamilan ini
( ) direncanakan
( ) diterima
( ) tidak direncanakan
( ) tidak diterima
b. Perasaaan tentang kehamilan ini : ......................................................................................
c. Emosional ibu saat pengkajian : .....................................................................................
d. Jenis kelamin yang diharapkan : ( ) laki-laki
( ) perempuan
(

) keduanya diterima

e. Status perkawinan
: Perkawinan ke ........., usia menikah ........... th dengan
suami ........... th. Lama perkawinan ......... bln/th. Status perkawinan ................................
f. Perilaku kesehatan

: ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

g. Pengambil keputusan dlm keluarga : (


4. Genogram
Ket :
: laki-laki
: perempuan
: hubungan tdk sedarah

) suami

) keluarga (

M : meninggal
: dengan penyakit ..................
--- : tinggal serumah

) ............................

5. Riwayat Obstetri
a. Riwayat Haid
Haid pertama
Siklus/lama haid
Banyaknya
b. Riwayat kehamilan
HPHT
TP
Keluhan-keluhan
Trimester I

: ....................... tahun
: .......... /........... hari
:........ kali ganti pembalut/hari

teratur/tidak teratur
sifat darah : ..............................
dismenorhe : ..............................

: ......... - ............ - .................


: ......... - ............ - .................
:
: ANC ........ kali, di ......................, keluhan .........................................
............................................................................................................
............................................................................................................
Trimester II : ANC ........ kali, di ......................, keluhan .........................................
............................................................................................................
............................................................................................................
Trimester III : ANC ........ kali, di ......................, keluhan ........................................
............................................................................................................
............................................................................................................

Pergerakan janin pertama kali dirasakan : hamil ......................... minggu


Bila pergerakan sudah terasa, pergerakan anak dalam 24 jam

( ) 10x
( ) 10x s/d 20x
( ) 20x

Bila lebih dari 20 kali dalam 24 jam, dengan frekuensi

( ) 15 detik
( ) 15 detik
( ) ....................

Bila ada pergerakan, keluhan yang dirasakan

: ...........................................................

6. Riwayat kehamilan, persalinan dan nifas yang lalu


Hamil
Jenis
Jenis
Tgl lahir bayi BBL
ke
kelamin persalinan

7. Riwayat KB
Jenis kontrasepsi
Kapan
Lama penggunaan
Keluhan
Alasan dilepas

G ......... P ........ A ........


Umur
penyulit Penolong
kehamilan

: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................

8. Riwayat kesehatan
Penyakit yang pernah atau sedang diderita
Penyakit
Jantung
Hipertensi
Hepar
Diabetes mellitus
PMS
Campak
Malaria
TBC
Lainnya

Klien

Keturunan Kembar dari pihak ibu/bapak

Keluarga

Keterangan

ada / tidak ada

9. Riwayat kebiasaan
a. Pola makan dan minum
.......................................................................................................................................................
.......................................................................................................................................................
b. Pola eliminasi
.......................................................................................................................................................
.......................................................................................................................................................
c. Pola istirahat dan tidur
.......................................................................................................................................................
.......................................................................................................................................................
d. Personal hygiene
.......................................................................................................................................................
.......................................................................................................................................................
e. Aktivitas sehari - hari
.......................................................................................................................................................
.......................................................................................................................................................
f. Seksualitas
.......................................................................................................................................................
.......................................................................................................................................................
g. Imunisasi
TT
( ) belum ( ) sudah ......... kali tanggal : I ............................. II ...........................
C. PEMERIKSAAN FISIK
1. Tanda Vital
Tekanan Darah
: ................ mmHg
Nadi
: ................ x/menit
Pernafasan
: ................ x/menit
Suhu
: ................ oC
2. Lingkar Lengan Atas
: ............... cm
3. Tinggi Badan
: ............... cm
4. Berat badan sebelum hamil
: ............... kg
Berat badan sekarang
: ............... kg

5. Kepala dan Rambut


Warna
: ...............................................................................................
Distribusi
: ...............................................................................................
Kebersihan
: ...............................................................................................
Kekuatan
: ...............................................................................................
Keadaan kulit kepala
: ...............................................................................................
6. Muka
Oedema
: ...............................................................................................
Pucat
: ...............................................................................................
Closmagravidarum
: ...............................................................................................
7. Mata
Conjungtiva
: ...............................................................................................
Sklera
: ...............................................................................................
Kemampuan penglihatan
: ...............................................................................................
8. Mulut
Gigi
: ...............................................................................................
Gusi
: ...............................................................................................
Mukosa bibir
: ...............................................................................................
9. Telinga
Pengeluaran
: ...............................................................................................
Kemampuan pendengaran
: ...............................................................................................
10. Hidung
Pengeluaran
: ...............................................................................................
Kemampuan penciuman
: ...............................................................................................
11. Leher
Pembesaran kel. Tiroid
: ...............................................................................................
Pembesaran kel. Getah bening: ...............................................................................................
Pembesaran vena jugularis : ...............................................................................................
12. Dada
Simetris
: ...............................................................................................
Pergerakan dada
: ...............................................................................................
13. Mammae
Kesimetrisan
: ...............................................................................................
Benjolan
: ...............................................................................................
Hiperpigmentasi areola
: ...............................................................................................
Bentuk payudara
: ...............................................................................................
Keadaan puting susu
: ...............................................................................................
Cairan yang keluar
: ...............................................................................................
14. Abdomen
Pembesaran
: ...............................................................................................
Warna
: ...............................................................................................
Bekas luka
: ...............................................................................................
Linea
: ...............................................................................................
Striae
: ...............................................................................................
Leopold I
: ...............................................................................................
Leopold II
: ...............................................................................................
Leopold III
: ...............................................................................................
Leopold IV
: ...............................................................................................
TBBJ
: ...............................................................................................
DJJ
: ...............................................................................................
15. Genitalia (vagina)
Oedema
: ..............................................................................................
Varises
: ...............................................................................................
Pembesaran kelenjar
: ...............................................................................................
Pengeluaran cairan
: ...............................................................................................
Bekas episiotomi
: ...............................................................................................
Kemerahan
: ...............................................................................................
Nyeri
: ...............................................................................................

Chadwick

: ...............................................................................................

16. Anus
Hemoroid

: ...............................................................................................

17. Ekstremitas
Tangan
: Kuku
Oedema
Kaki
: Varises
Oedema
Refleks Patella
18. Punggung
Lordosis
Kiposis
Skoliosis
Ketuk costovertebra
19. Ukuran Panggul Luar
Distansia Spinarum
Distansia Kristarum
Conjunggata eksterna
Lingkar panggul
20. Ukuran Panggul Dalam

: ...............................................................................................
: ...............................................................................................
: ...............................................................................................
: ...............................................................................................
: ( ) tidak ada
( ) ada,
kanan ( )
kiri ( )
:(
:(
:(
:(

) Ya
) Ya
) Ya
) Ya

(
(
(
(

) Tidak
) Tidak
) Tidak
) Tidak

: .............. cm
: .............. cm
: .............. cm
: .............. cm
: .............................

(normal : 25 26 cm)
(normal : 26 28 cm)
(normal : 18 19 cm)
(normal : 80 90 cm)

D. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ......................................
Pukul : .............................
a. Darah
b. Urine
Hb
: ................ gr %
Protein
: ...............................
Gol. Darah
: ................
Reduksi
: ...............................
Rhesus
: ................
2. Pemeriksaan Penunjang Lainnya
.............................................................................................................................................................
.............................................................................................................................................................
....................................., ....................................
Pembimbing Lahan Praktek

Mahasiswa

( ................................................... )
NIP.

( MARIATI)
NIM. PO.62.24.2.10.112

Pembimbing Praktek Dari Insitusi

( .............................................. )
NIP.

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