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
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

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

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

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

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

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

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

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

Sign up to vote on this title
UsefulNot useful