PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS RIAU
KEPERAWATAN MATERNITAS
PENGKAJIAN PRENATAL
Nama Mahasiswa

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Tanggal pengkajian :
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Ruangan

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I.PENGKAJIAN
DATA UMUM KLIEN
1. Inisial klien
2. Usia

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3. Status perkawinan
4. Pekerjaan

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5. Pendidikan terakhir

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II.ALASAN DATANG
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III.KELUHAN UTAMA SAAT PENGKAJIAN
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.....................P... BB sebelum hamil :.... Minggu : Keadaan umum : Kesadaran : BB/TB : ..................... Masalah Ginekologi: 2.............. Taksiran Partus :..Kg TD sebelum hamil :.....................................H......................... Riwayat KB : Riwayat kehamilan saat ini HPHT :................ DATA UMUM KESEHATAN PADA SAAT INI Status Obstetrik : G........cm Tanda vital Tekanan darah : ...................................................kg/............................ IV.. .........................Riwayat Kehamilan dan Persalinan Yang lalu NO TAHUN JENIS PERSALINAN PENOLONG JENIS KELAMIN MASALAH KEHAMILAN 1 2 3 4 5 Pengalaman menyusui : ya/tidak Berapa lama : Riwayat ginekologi 1..............A.mmHg Nadi:...

.ºC Pernafasan : ...Suhu : ............x/menit .........

........................................................................................................................................ Hidung : ................................................................................................... Payudara : ...................Kepala Leher Kepala : ......................................... Telinga : ............................................................. Masalah keperawatan : ....... Leher : ............................................................................................................................................................................................................................................................................................................................................................................. Dada Jantung : ............... Pengeluaran ASI : ...................................................... .............................................................................................................................................................................................................................................. Masalah Keperawatan : ................................................................................................................................................................................................ Puting susu : ................................................................................................................................... Mulut : .........................................cm Kontraksi : ya/tidak ............................. . Abdomen Uterus Tinggi fundus uteru : ...... Paru-paru : .................................................................................................................................................................................. Mata : ..............................................................................................................................

.............................................................................. Ekstremitas Ekstremitas atas .................................................................................................................................... ............................. Masalah Keparawatan : ....................................................................... Frekuensi DJJ : .. Nyeri : ya/ tidak : ...........................................................................................................x/menit Pigmentasi Linea nigra : .............................................................. Perineum dan Genitalia Vagina : Kebersihan : ....... Konsistensi : ....................................................... Lokasi : .................................................................................................................................. Bau : ................................................................................ Keputihan : Hemoroid Masalah keperawatan : varises : ya/ tidak jenis/ warna : ...................................................................................................................................................................................... derajat : ............ Bising usus : ...................................................................................................................................................................................................................................................................... .............................................................. Striae : ........................Leopold I : kepala/ bokong/ kosong Leopold II : Kanan : punggung/ bagian kecil/ bokong/ kepala Kiri : punggung/ bagian kecil/ bokong/ kepala Leopold III : kepala/ bokong/ kosong Penurunan kepala : sudah/ belum Leopold IV : Bagian masuk PAP: ....................................................................................................................................................................................

............ Varises : ya/ tidak lokasi: ...................................................................................................................... Masalah keperawatan : ................ Eliminasi Urin : kebiasaan BAK : .... ........................................................ Reflek patella : +/ - jika ada: +1/ +2/ +3 Ekstremitas bawah Masalah keperawatan : .................................................................................................................................................. ..Edema : ya/ tidak lokasi: ......................................................................................................................................... Varises : ya/ tidak lokasi: ...................................................................................................................................... BAB : kebiasaab BAB : .................................................................................................................................. Edema : ya/ tidak lokasi: ............... .............................................

............................. Sifat : ..................................................................................................................................................................... Penerimaan terhadap kehamilan : .............................................................................................................................................................................. Masalah keperawatan : ...................................... ............................................... .................................................................................................................................. Latihan/ senam : ...........................................................................jam frekuensi:...... Masalah keperawatan :............................................. : ........................................................... .................... .. ........................................ : ya/tidak Lokasi : ................................................................................................................................................................................................................................................................................................................... Pola tidur saat ini : keluhan ketidaknyamanan Masalah keperawatan lama:.................................................................................................................................Istirahat dan kenyamanan Pola tidur : kebiasaan tidur: .............................. Nafsu makan : baik/ kurang/ tidak ada Asupan cairan : cukup/ kurang Masalah keperawatan : .................................................................................................................................... Mobilisasi dan latihan Tingkat mobilisasi : .. Intensitas : ................................................................................................................................................................................................. Nutrisi dan Cairan Asupan nutrisi : ................................................................................................ Keadaan Mental Adaptasi psikologis : ...

.......................................... .................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................. Hasil pemeriksaan penunjang: ..................................................................... ........................................................................................ Pekanbaru........................................................................................Pola hidup yang meningkatkan resiko kehamilan: ..................................................................................2013 mahasiawa .................................................................................................................................... Persiapan persalinan: • Senam hamil • Rencana tempat melahirkan • Perlengkapan kebutuhan bayi dan ibu • Kesiapan mental ibu dan keluarga • • Pengetahuan tentang tanda-tanda melahirkan................................................ .............................. ............. cara penganan nyeri dan proses persalinan Perawatan payudara Obat-obat yang dikonsumsi saat ini: ........................................................................................... ....................................................................................................... .........................

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