PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS RIAU
KEPERAWATAN MATERNITAS
PENGKAJIAN PRENATAL
Nama Mahasiswa

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Tanggal pengkajian :
NIM

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

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

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

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

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

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

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

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