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Format Pengkajian

Format Pengkajian

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Dipublikasikan oleh Rully Indarsyah
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Categories:Types, Brochures
Published by: Rully Indarsyah on Apr 21, 2013
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07/06/2015

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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. !a!us pe"kawinan :
#. $eke"jaan :
%. $en&i&ikan !e"akhi" :
II.ALASAN DATANG
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
III.KELUHAN UTAMA SAAT PENGKAJIAN
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
Riwa'a! Kehamilan &an $e"salinan (ang lalu
N) TA*UN +ENI
$ERALINAN
$EN)L)N, +ENI
KELAMIN
MAALA*
KE*AMILAN
1
2
3
#
%
$engalaman men'usui : 'a-!i&ak
.e"apa lama :
Riwayat ginekoogi
1. Masalah ,inek/l/gi:
2. Riwa'a! K. :
Riwayat ke!a"ian #aat ini
*$*T :...................................... Taksi"an $a"!us :............................................................
.. se0elum hamil :......................................Kg
TD se0elum hamil :......................................
IV. DATA UMUM KESEHATAN PADA SAAT INI
!a!us )0s!e!"ik : ,.....$.....A.....*..... Minggu :
Kea&aan umum :
Kesa&a"an :
..-T. : .............kg-............1m
Tan$a %ita
Tekanan &a"ah : ............mm*g Na&i:........................................
uhu : ............23
$e"na4asan : ............5-meni!
Ke&aa Le!e'
Kepala : ...................................................................................................................
Ma!a : ...................................................................................................................
*i&ung : ...................................................................................................................
Mulu! : ...................................................................................................................
Telinga : ..................................................................................................................
Lehe" : ...................................................................................................................
Masalah kepe"awa!an : ..................................................................................................................
.....................................................................................................................
Da$a
+an!ung : ..................................................................................................................
$a"u6pa"u : ..................................................................................................................
$a'u&a"a : ..................................................................................................................
$u!ing susu : ..................................................................................................................
$engelua"an AI : ...................................................................................................................
Masalah Kepe"awa!an : ...................................................................................................................
.....................................................................................................................
A($o"en
U!e"us
Tinggi 4un&us u!e"u : ...............1m
K/n!"aksi : 'a-!i&ak
Le/p/l& I : kepala- 0/k/ng- k/s/ng
Le/p/l& II : Kanan : punggung- 0agian ke1il- 0/k/ng- kepala
Ki"i : punggung- 0agian ke1il- 0/k/ng- kepala
Le/p/l& III : kepala- 0/k/ng- k/s/ng
$enu"unan kepala : su&ah- 0elum
Le/p/l& I7 : .agian masuk $A$: .........................
8"ekuensi D++ : .............................5-meni!
$igmen!asi
Linea nig"a : ........................................................................................................................
!"iae : ........................................................................................................................
.ising usus : .......................................................................................................................
Masalah Kepa"awa!an : .......................................................................................................................
..........................................................................................................................
Pe'ine)" $an Genitaia
7agina : 9a"ises : 'a- !i&ak
Ke0e"sihan : ........................................................................................................................
Kepu!ihan : jenis- wa"na : ...........................................................................................
K/nsis!ensi : ...........................................................................................
.au : ............................................................................................
*em/"/i& : &e"aja! : ............................................................................................
L/kasi : ............................................................................................
N'e"i : 'a- !i&ak
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
Ek#t'e"ita#
Eks!"emi!as a!as
E&ema : 'a- !i&ak l/kasi: ......................................
7a"ises : 'a- !i&ak l/kasi: ......................................
Eks!"emi!as 0awah
E&ema : 'a- !i&ak l/kasi: ......................................
7a"ises : 'a- !i&ak l/kasi: ......................................
Re4lek pa!ella : :- 6 jika a&a: :1- :2- :3
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
Ei"ina#i
U"in : ke0iasaan .AK : .........................................................................................
.A. : ke0iasaa0 .A. : .........................................................................................
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
I#ti'a!at $an kenya"anan
$/la !i&u" : ke0iasaan !i&u": ........................... lama:........jam 4"ekuensi:..............
$/la !i&u" saa! ini : keluhan ke!i&akn'amanan : 'a-!i&ak
L/kasi : .......................................
i4a! : ........................................
In!ensi!as : .......................................
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
Mo(ii#a#i $an ati!an
Tingka! m/0ilisasi : ........................................................................................................................
La!ihan- senam : ........................................................................................................................
Masalah kepe"awa!an :........................................................................................................................
.........................................................................................................................
N)t'i#i $an *ai'an
Asupan nu!"isi : ......................................................................................................................
Na4su makan : 0aik- ku"ang- !i&ak a&a
Asupan 1ai"an : 1ukup- ku"ang
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
Kea$aan Menta
A&ap!asi psik/l/gis : ........................................................................................................................
$ene"imaan !e"ha&ap kehamilan : .............................................................................................................
Masalah kepe"awa!an : ........................................................................................................................
..........................................................................................................................
$/la hi&up 'ang meningka!kan "esik/ kehamilan: ...............................................................................
..............................................................................................................................................................
...............................................................................................................................................................
$e"siapan pe"salinan:
• enam hamil
• Ren1ana !empa! melahi"kan
• $e"lengkapan ke0u!uhan 0a'i &an i0u
• Kesiapan men!al i0u &an kelua"ga
• $enge!ahuan !en!ang !an&a6!an&a melahi"kan; 1a"a penganan n'e"i &an p"/ses pe"salinan
• $e"awa!an pa'u&a"a
)0a!6/0a! 'ang &ik/nsumsi saa! ini: ....................................................................................................
................................................................................................................................................................
..................................................................................................................................................................
*asil peme"iksaan penunjang: ..................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
$ekan0a"u. ................;2<13
mahasiawa

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

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