Format Pengkajian

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS RIAU
KEPERAWATAN MATERNITAS
PENGKAJIAN PRENATAL
Nama Mahasiswa

:

Tanggal pengkajian :
NIM

:

Ruangan

:

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

:

:

3. Status perkawinan
4. Pekerjaan

:

:

5. Pendidikan terakhir

:

II.ALASAN DATANG
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
III.KELUHAN UTAMA SAAT PENGKAJIAN
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

............... BB sebelum hamil :....H...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.....................................................mmHg Nadi:........... Taksiran Partus :.......A.........cm Tanda vital Tekanan darah : ..............................P.. Minggu : Keadaan umum : Kesadaran : BB/TB : ................................................ Masalah Ginekologi: 2.... DATA UMUM KESEHATAN PADA SAAT INI Status Obstetrik : G.......Kg TD sebelum hamil :..................kg/................ IV........................ ... Riwayat KB : Riwayat kehamilan saat ini HPHT :.....................

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

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

.................................................... Nyeri : ya/ tidak : ....................... Konsistensi : ............................... ..................................... Perineum dan Genitalia Vagina : Kebersihan : .......................................................................... Masalah Keparawatan : .....................................................................................................x/menit Pigmentasi Linea nigra : .................................................................................................................................................................. derajat : ................................................................................................................................................................................................................................................................................................................................................................. Keputihan : Hemoroid Masalah keperawatan : varises : ya/ tidak jenis/ warna : ........................................................................................... .......................................................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: ................................................................................................................................................................................................. Bising usus : ........................ Lokasi : ......................... Bau : ............................................................ Ekstremitas Ekstremitas atas .............................. Striae : ......................................................................................... Frekuensi DJJ : ...........................................................................

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

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

.............. ....................................................................................................................................................................................................................................................................................................................... .................................................................................... ......................... ...... ........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: ................................................................................Pola hidup yang meningkatkan resiko kehamilan: ......... ....................................... Pekanbaru........................................................................................................................... Hasil pemeriksaan penunjang: ........................

Sign up to vote on this title
UsefulNot useful