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
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III.KELUHAN UTAMA SAAT PENGKAJIAN
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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. Masalah Ginekologi:
2. Riwayat KB

Riwayat kehamilan saat ini

HPHT

:...................................... Taksiran Partus

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

BB sebelum hamil :......................................Kg

TD sebelum hamil :......................................

IV. DATA UMUM KESEHATAN PADA SAAT INI

Status Obstetrik : G.....P.....A.....H..... Minggu :
Keadaan umum :
Kesadaran

BB/TB

: .............kg/............cm

Tanda vital
Tekanan darah

: ............mmHg

Nadi:........................................

Suhu

: ............C

Pernafasan

: ............x/menit

Kepala Leher
Kepala

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

Mata

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

Hidung

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

Mulut

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

Telinga

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

Leher

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

Masalah keperawatan

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

Dada
Jantung

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

Paru-paru

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

Payudara

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

Puting susu

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

Pengeluaran ASI

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

Masalah Keperawatan

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

Abdomen
Uterus
Tinggi fundus uteru : ...............cm
Kontraksi

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

Frekuensi DJJ

: .............................x/menit

Pigmentasi
Linea nigra

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

Striae

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

Bising usus

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

Masalah Keparawatan

: .......................................................................................................................
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Perineum dan Genitalia

Vagina

Kebersihan

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

Keputihan

Hemoroid

Masalah keperawatan

varises

: ya/ tidak

jenis/ warna : ...........................................................................................

Konsistensi

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

Bau

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

derajat

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

Lokasi

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

Nyeri

: ya/ tidak

: ........................................................................................................................
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Ekstremitas
Ekstremitas atas

Edema

: ya/ tidak

lokasi: ......................................

Varises

: ya/ tidak

lokasi: ......................................

Edema

: ya/ tidak

lokasi: ......................................

Varises

: ya/ tidak

lokasi: ......................................

Reflek patella

: +/ -

jika ada: +1/ +2/ +3

Ekstremitas bawah

Masalah keperawatan

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

Eliminasi
Urin

: kebiasaan BAK : .........................................................................................

BAB

: kebiasaab BAB : .........................................................................................

Masalah keperawatan

: ........................................................................................................................
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Istirahat dan kenyamanan

Pola tidur

: kebiasaan tidur: ...........................

Pola tidur saat ini

: keluhan ketidaknyamanan

Masalah keperawatan

lama:........jam

frekuensi:..............

: ya/tidak

Lokasi

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

Sifat

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

Intensitas

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

: ........................................................................................................................
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Mobilisasi dan latihan

Tingkat mobilisasi

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

Latihan/ senam

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

Masalah keperawatan

:........................................................................................................................
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Nutrisi dan Cairan

Asupan nutrisi

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

Nafsu makan

: baik/ kurang/ tidak ada

Asupan cairan

: cukup/ kurang

Masalah keperawatan

: ........................................................................................................................
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Keadaan Mental
Adaptasi psikologis

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

Penerimaan terhadap kehamilan : .............................................................................................................

Masalah keperawatan

: ........................................................................................................................
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Pola hidup yang meningkatkan resiko kehamilan: ...............................................................................

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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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Hasil pemeriksaan penunjang: ..................................................................................................................

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Pekanbaru. ................,2013

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