PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS RIAU
KEPERAWATAN MATERNITAS
PENGKAJIAN PRENATAL
Nama Mahasiswa

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

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

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

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

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

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

..................................................................................................................... cara penganan nyeri dan proses persalinan Perawatan payudara Obat-obat yang dikonsumsi saat ini: ....................................... ......................................................................... .................. Pekanbaru........................................................................................................................................................................... Hasil pemeriksaan penunjang: ............................................................................................................................... ..............................................................................................................................................................................................2013 mahasiawa .............................................. ............ ...Pola hidup yang meningkatkan resiko kehamilan: ................................................................................................ 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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