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

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

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

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

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

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

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

Master your semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master your semester with Scribd & The New York Times

Cancel anytime.