Pengkajian Prenatal

ASUHAN KEPERAWATAN PADA Ny

DENGAN ..
Di RUANG
TANGGAL .

A. PENGKAJIAN
I.

IDENTITAS PASIEN
Nama

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

Umur

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

Pendidikan

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

Pekerjaan

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

Status perkawinan : .......................................

Agama

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

Suku

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

Alamat

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

No. CM

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

Tanggal MRS

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

Tanggal pengkajian: ........................................

Sumber Informasi : ........................................
Diagnosa masuk

II.

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

PENANGGUNG/ SUAMI
Nama

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

Umur

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

Pendidikan

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

Pekerjaan

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

Alamat

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

Hubungan dengan pasien : ........................................

III. ALASAN KUNJUNGAN

Keluhan utama (saat ke poliklinik)

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IV. RIWAYAT OBSTETRI DAN GINEKOLOGI

A. Riwayat Menstruasi :
Menarche

: umur .................

Siklus

: teratur ( )

tidak ( )

Banyaknya

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

Lamanya

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

Keluhan

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

HPHT

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

B. Riwayat Pernikahan :
Menikah : ................. kali

Lama : ............... tahun

C. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke
No

Tahun

Kehamilan
Umur
Kehamilan

Penyulit

Persalinan
Jenis

Penolong

Komplikasi Nifas
Penyulit

Laserasi

Infeksi

Perdarahan

Anak
JK

BB

Pj

D. Riwayat Kehamilan Saat Ini

Status obstetrik :
G...P....A...H...
TP

UK : ....................

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

ANC kehamilan ini : ...........................................(tuliskan riwayat ANC nya)

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E. Riwayat Keluarga Berencana :
Akseptor KB

: jenis .....................

Lama : .........................

Masalah

: ................................................ (tuliskan riwayat kontrasepsi)

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F. Riwayat Penyakit Klien dan Keluarga
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V.

POLA FUNGSIONAL KESEHATAN

a.

Pemeliharaan dan persepsi terhadap kesehatan

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b.

Nutrisi/ metabolic
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c.

Pola eliminasi
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d.

Pola aktivitas dan latihan

Kemampuan perawatan diri

Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total
Keterangan :

e.

Pola tidur dan istirahat

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f.

Pola perseptual
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g.

Pola persepsi diri

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h.

Pola seksual dan reproduksi

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i.

Pola peran-hubungan
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j.

Pola manajemen koping stress

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k.

Sistem nilai dan keyakinan

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V. PEMERIKSAAN FISIK
Keadaan Umum
GCS

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

Tingkat Kesadaran : .......................................................................................

Tanda-tanda vital : TD ............... N ................. RR ................ T................
BB

: ..................... TB ................ LILA : ......................

Head to toe
Kepala

Wajah

Mata

Leher

Dada

Payudara

Inspeksi :
Areola .................

Puting : (menonjol/tidak)

Tanda dimpling/retraksi : ....................................

Palpasi : Pengeluaran ASI ......................
Adanya nodul : ...........................

Jantung dan Paru :

Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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Abdomen :

Inspeksi

: Linea : .................. Striae

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

Pembesaran sesuai UK : .......................

Gerakan janin : ............................... kontraksi : ....................
Luka bekas operasi : ............................

Auskultasi

: DJJ : ........ Bising usus :

Palpasi

:
Ballotement

: .

Leopold I

: . TFU : ..

Leopold II

: kanan :
Kiri

Leopold III

Leopold IV

Penurunan kepala

(penurunan bag terbawah dg metode 5 jari)

Kontraksi

Perkusi

.........................................................................................................
Genetalia dan Perineum :

Kebersihan

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

Keputihan

: ................................................ karakteristik : ,...................

VT

: ................................................ (jika ada)

Anus

Hemoroid

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

Perdarahan

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

Karakteristik : ............................................................................................

Ekstremitas :
Atas dan bawah (hasil dibuat terpisah)
(oedema, varises, CRT, kekuatan otot, tonus)

VI. DATA PENUNJANG

a.

Data laboratorium yang berhubungan

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b.

Pemeriksaan USG
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VII.

DIAGNOSA MEDIS
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VIII.

PENGOBATAN
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B.

ANALISA DATA
DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN
RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN
NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

Mengetahui,
Pembimbing klinik/CI

Mahasiswa

(...................................)

(.............................................)

NIP.

NIM.
Clinical Teacher/ CT

(...............................................)
NIP.