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FORMAT ASKEP IBU HAMIL (ANC)

PENGKAJIAN
I. IDENTITAS
Nama ibu

Nama suami

:
Umur

Umur

Pendidikan

Pendidikan :

Agama

Agama

Pekerjaan

Status perkawinan

Alamat

:
Pekerjaan

Tanggal pengkajian

Diagnosa medis

2. DATA SUBJEKTIF
a. keluhan utama
.......................................................................................................................................
.......................................................................................................................................
b. riwayat Kesehatan Sekarang
.......................................................................................................................................
.......................................................................................................................................
c. Riwayat Kehamilan Sekarang
ANC(Ante Natal Care) :.........................teratur/tidak.................................................
Diperiksa

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

Imunisasi

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

Usia kehamilan : .............................................................................................


d. Riwayat Menstruasi
Menarche

....................siklus......................lamanya..........teratur/tidak...........

Jumlah :......................Warna:..................dismenorhe:...................................
HPHT

:......................taksiran persalinan persalinan..............

e. Riwayat obsteri
G.............................P.................................A........................................................
.
ANAK
KE

JENKEL

UMUR

RIWAYAT PERSALINAN
LANIR

USIA
HAMIL

f. Riwayat Kesehatan / Penyakit Yang lalu

PENOLONG

PENYULIT

BBL

KET

penyakit
alergi
merokok dan obat-obatan
g. Riwayat penyakit Keluarga
.......................................................................................................................................
.......................................................................................................................................
h. Keadaan Psikososial

Perubahan kehamilan terhadap kehidupan sehari-hari.


...........................................................................................................................

Harapan yang didinginkan selama kehamilan


...........................................................................................................................

Ibu tinggal serumah dengan siapa


...........................................................................................................................

Yang menemani ibu ke klinik


...........................................................................................................................

Rencana melahirkan
...........................................................................................................................

Rencana menyusui
...........................................................................................................................

i. Seksual

dampak kehamilan terhadap perubahan pola


seksual ...............................................................................................................................
...........
j. riwayat keluarga Berencana
Jenis kontrasepsi yang pernah digunakan
...........................................................................................................................
......
Masalah-masalah yang dailami selama kehamilan
............................................................................................................................
......
Jumlah anak yang direncanakan
.............................................................................................................................
.....
k. pola kehidupan sehari-hari
Pola makan
Diet kebiasaan (jenis)
...........................................................................................................................
.
Perubahan dalam pola makan
...........................................................................................................................
.
Pandangan selama kehamilan terhadap makanan
...........................................................................................................................
.
Masalah mengunyah/menelan
...........................................................................................................................
.
Kenyamanan, aktivitas dan istirahat
Kenyamanan selama kehamilan dan cara mengatasinya
...........................................................................................................................
.
Aktivitas/hobi kebiasaan
...........................................................................................................................
.
Aktivitas kesenangan
...........................................................................................................................
. Pembatasan selama kehamilan kondisi

...........................................................................................................................
.
Perubahan istirahat, tidur,dan cara mengatasinya
...........................................................................................................................
Jumlah jam istirahat/ tidur perhari
...........................................................................................................................
. Pola eleminasi
Buang Air Besar

Dampak kehamilan terhadap pola eleminasi


Frekuensi BAB
:...............x/ hari
Nyeri/ rasa panas saat BAB
Perdarahan
Hemoroid
Konstipasi
Diare

Buang Air Kecil


Frekuensi BAK
Kesulitan Berkemih
Dorongan
Personal higine
Frekuansi mandi
Frekuensi gosok gigi
Perawatan Payudara
Vulva Higine

:...............x/hari
Riwayat Penyakit Ginjal
Penggunaan diuretik
:...................X/hari
:...................x/hari
:......................
:......................

3. PEMERIKSAAN FISIK
a. secara umum
Tanda- tanda vital
Tekanan darah
:......................................mm/Hg
Suhu
:......................................C
Nadi
:......................................x/ menit
Pernapasan
:......................................x/ menit
Berat badan sekarang
:......................................Kg
Berat Badan sebelum lahir :..........................Kg
LILA
:......................................Cm
b. Secara head To Toe

Kepala
Rambut
Muka
Mata/ konjungtiva

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

Hidung
:...........................
Mulut
:...........................
Leher
Inspeksi
: Gondok
:..........................................................
Palpasi
: Masa
:..........................................................
Auskultasi
: Bruit Aorta
:..........................................................
Dada
Payudara membersar :.......................
Puting susu
:.......................
Kebersihan
:.......................
Simetris
:.......................
Abdomen
Inspeksi
Straiae Gravidarum :....................................
Hiperpigmentasi
:....................................
Auskultasi
DJJ
:.....................................
Bising usus
:.....................................
Palpasi
Leopold I
:.....................................
Leopold II
:.....................................
Leopold III
:.....................................
Leopold IV
:.....................................
Perkusi
:.....................................

Ekstremitas
Kekuatan otot :.....................................
Reflek Patela
:.....................................
Reflek Babinski
:.....................................
Edema
:.....................................
Chubb
:.....................................
c. pemeriksaan laboratorium
HB

:...........................Gol. Darah
:...............................................Rh+/:........................................................................................................

Urine
..
USG
:.............................................................................................
.............
d. data penunjang therapy

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

ANALISA DATA
DATA

PENYEBAB

MASALAH

DO
...................................
.
DS
...................................

RENCANA INTERVENSI

NO

DIAGNOSA

TUJUAN

KRITERIA
HASIL

INTERVENSI

RASIONALISASI

IMPLEMANTASI DAN RASIONALISASI

NO.
DIAGNOSA

HARI/TANGGAL

TINDAKAN

EVALUASI

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