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FORMAT PENGKAJIAN PADA IBU HAMIL

MAHASISWA PROGRAM D III KEPERAWATAN


STIKES NANI HASANUDDIN MAKASSAR
No. Reg. Ibu
: ..............................Nama
Mahasiswa :..................................
Tgl. Kunjungan
: ..............................Tgl. Pengkajian
I.

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

BIODATA
A. IDENTITAS IBU / SUAMI :
Nama
: ....................................../...........................................
Umur
: ................tahun / .....................tahun
Suku / bangsa : ...................................../ ...........................................
Agama
: ...................................../ ..........................................
Pend. Terakhir : ...................................../ ...........................................
Pekerjaan
: ...................................../ .................................
Lamanya menikah:...................................
Alamat
: ...................................................................................
B. DATA BIOLOGIS / FISIOLOGIS
1. Keluhan utama (mual/muntah, pusing / sakit kepala, keluar darah,
dll):.......................................................................................................
.............................................................................................................
.........................................
2. Riwayat keluhan :
a. Mulai
timbulnya ........................................................................................
.................
b. Sifat keluhan (kwalitas / kwantitas)
.........................................................................................................
.........................................................................................................
.........................................................................................................
....................
c. Lokasi
keluhan .......................................................................................
d. Faktor pencetus
........................................................................................
e. Keluhan
lain ..................................................................................... .......
f. Pengaruh keluhan terhadap aktifitas / fungsi tubuh
.........................................................................................................
.........................................................................................................
.........................................................................................................
...

g. Usaha klien untuk mengatasi keluhan


......................................................................................................
3. Riwayat kesehatan masa lalu :
a. Penyakit yang pernah di derita .....................................................
b. Riwayat opname ( kapan/alasan)....................................................
c. Riwayat trauma ( kapan/alasan)
......................................................................................................
.......................................................................................................
......................................................................................................
d. Riwayat operasi (kapan/alasan) ...................................................
e.
Riwayat tranfusi darah ( kapan, alasan, reaksi)
:......................................................................................................
.......................................................................................................
......................................................................................................
4. Riwayat kehamilan dan persalinan serta nifas yang lalu :

N
o

Kehamilan
Umu Keadaa
r
n

Thn

Persalinan
Tempa Penolon
t
g

5. Pola Reproduksi :
a. Menarche umur
b. Siklus haid
c. Lamanya haid
d. Sifat darah
e. Dysmenorhoe

Jeni
s

P/L

Anak
Lamany Keadaa
a
n skrg
menyus
ui

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

6. Riwayat pola kegiatan sehari-hari :


a. Nutrisi :
Kebiasaan :
1) Pola makan .................................................................
2) Frekuensi makanan sehari ..........................................
3) Kebutuhan minuman / cairan .....................................

Riwaya
t Nifas

Selama hamil :
1) Konsumsi perhari makanan sumber :
Karbohidrat ................................
Protein ........................................
Lemak .........................................
2) Nafsu makan .................................................................
3) Masalah dengan gigi/mengunyah ................................
4) Makanan yang disenangi .............................................
5) Makanan yang di pantang ............................................
6) Keluhan minum/cairan .................................................
7) Perubahan lain .............................................................
b. Eliminasi :
Kebiasaan :
1) Frekuensi BAK: ....................................................
2) Warna/bau khas : ...................................................
3) Gangguan eliminasi BAK :....................................
4) Frekuensi BAB :....................................................
5) Warna/konsistensi BAB :......................................
Selama hamil :
1) Poliuri :...................................................................
2) Incontinensia uri :...................................................
3) Dysuri :..................................................................
4) Hemoroid :.............................................................
5) Konstipasi :...........................................................
6) Perubahan lain ....................................................
c. Kebutuhan kebersihan diri sendiri :
Kebiasaan :
1) Kebersiahan rambut : ................................................
2) Kebersihan badan :....................................................
3) Kebersihan gigi/mulut :.............................................
4) Kebersihan genetalia dan anus :...............................
5) Kebersihan kuku tangan/kaki :..................................
6) Kebersihan pakaian :.................................................
Perubahan selama hamil
...................................................................................................
...................................................................................................
d. Kebutuhan rekreasi / olah raga :
Kebiasaan :
1) Jenis / frekuensi rekreasi : .........................................
2) Jenis / fekuensi olah raga :.........................................
3) Jenis rekreasi / olah raga :..........................................
Perubahan selama hamil :
....................................................................................................
....................................................................................................

e. Kebutuhan istirahat /tidur :


Kebiasaan :
1) Istirahat/tidur siang :..............................................
2) Istirahat/tidur malam :...........................................
3) Pekerjaan RT dilakukan : .....................................
4) Merawat anak dilakukan :....................................

f.

Selama hamil :
1) Perubahan : ...........................................................................
................. .............................................................................
.................
2) Peranan keluarga dalam membantu ibu istirahat :
...............................................................................................
...............................................................................................
Kebutuhan seksual ( bila mungkin / perlu )
1) Kebiasaan : .........................................................................
2) Perubahan selama
hamil : ...................................................................................
...............................................................................................
........

7. Pemerikasaan Fisik
a. Pemeriksaan fisik umum :
1) Penampilan ibu : ......................................................
2) Kesadaran : ..............................................................
3) Tinggi/BB: ...................Cm / ....................Kg
4) Tanda Vital :
Tekanan darah : .......................mmHg
Denyut nadi : .........................../menit
Temperatur /suhu : ........................... oC
Respirasi : ................................/menit
5) Inspeksi kepala dan rambut :
Keadaan rambut : .................................................
Kebersihan rambut : .............................................
6) Inspeksi wajah/muka :
Edema wajah/muka : ............................................
Topeng kehamilan : .............................................
Ekspresi wajah : .................................................
7) Mata :
Kebersihan : ........................................................
Konjungtiva : ......................................................
Sklera : ..............................................................
Kelopak mata : ...................................................

8) Inspeksi hidung :
Kesimetrisan : .....................................................
Sekret hidung : ....................................................
Epistaksis : .........................................................
9) Inspeksi gigi dan hidung :
Kebersihan gigi / mulut : ..........................................
Keadaan gigi : ...........................................................
Keadaan gusi : ...........................................................
Keadaan lidah : ..........................................................
Keadaan mukosa bibir : ............................................
Caries / protese : ........................................................
10)

Inspeksi telinga :
Kebersihan telinga : .........................................................
Sekret telinga :..................................................................
Keadaan telinga luar : .....................................................

11)

Inspeksi / palpasi leher :


Pembesaran kelenjar gondok : .......................................
Pembesaran vena jugularis : ............................................
Pembesaran arteri karotis : ..............................................

12)
Inspeksi / palpasi dan auskultasi dada
/perut :
a.
Payudara :
- Kesimetrisan : ....................................
- Keadaan puting : ................................
- Keadaan areola : ................................
- Kolostrum : .......................................
b.
Jantung
- Bunyi jantung : .......................................
- Bunyi tambahan : ...............................
c.
Paru
- Bunyi pernafasan : .............................
- Bunyi tambahan : ..............................
d.
Abdomen
- Pembesaran : ..........................................................
- Bentuk : .................................................................
- Striae : ...................................................................
- Linea : ...................................................................
- Tanda hidramnion : ...............................................
- Tampak gerakan janin : ........................................
- Peristaltik usus : ..................................................
13)
Inspeksi genetalia (vulva/anus)
a. Kebersihan : ................................................................
b. Tanda chadwick : ........................................................

c.
d.
e.
f.

Varises : .......................................................................
Flour albus : ................................................................
Kondilomata : ................................................................
Pembesaran kel. lipat paha : ........................................

14)
Inspeksi dan palpasi tungkai bawah :
a. Kesimetrisan : .............................................................
b. Edema pretibial : ........................................................
c. Varises : .....................................................................
b. Pemeriksaan Obstetri
1. Palpasi ( Leopold)
a. Tinggi Fundus Uteri : ...............................................
b. Posisi janin : .............................................................
c. Presentasi janin : ......................................................
d. Masuknya presentasi : ............................................
2. Auskultasi DJJ
a. Irama/regularitas : ..................................................
b. Frekuensi :.........................................kali / menit
c. Gerakan usus : .......................................................
3. Pemeriksaan panggul (tgl pengukuran)
a. Distansia spinarum : ...............cm
b. Distansia kristarum : ...............cm
c. Konjugata eksterna : ................cm
d. Distansia tuberum : ..................cm
e. Ukuran lingkar perut : ..........cm
4. Pemerikasaan laboratorium (hasil tgl)
a. Urine :
- Albumin : ................................
b. Darah :
- HB
- Golongan darah
c. Keluarga Berencana
- Apakah ibu mengerti tentang KB : ..............................
- Apakah ibu setuju dengan KB : ...................................
- Apakah ibu pernah menjadi akseptor : .......................
- Apakah metode kontrasepsi yang digunakan : ...........
- Apakah pernah drop out /berhenti: ...................
alasannya...................... ........................
d. Data Psikologis /sosiologis
a. Reaksi emosional terhadap kehamilan
- Rencana untuk hamil : ...........................................
- Respon ibu : ..........................................................
- Respon suami : ......................................................
- Respon Keluarga :..................................................
b. Peranan ibu dalam keluarga
- pengambilan keputusan : ......................................
- konsultasi kesehatan : ..........................................

- Penentuan diet dan makan pantang : ....................


- Lain-lain : ..............................................................
e. Data Spritual
1. Hubungan keyakinan ibu dengan
kehamilannya :.................... .......................................
...............
2. Usaha ibu untuk berdoa terhadap
kesehatannya :..................... ......................................
.................
3. Pantangan menurut keyakinan ibu selama
kehamilan :............ .....................................................
..........
4. Keharusan menurut keyakinan ibu selam
kehamilan :.............. ...................................................
..............
f. Data tambahan lain :
1. Keluarga
klien : ........................................................................
2. Tim kesehatan yang
terlibat :.................................................... ..................
..................................................................

Makassar, ....... .....................201


5
Mahasiswa yang bersangkutan,

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

FORMAT PENGKAJIAN PADA IBU INPARTU MAHASISWA


PROGRAM D III KEPERAWATAN
STIKES NANI HASANUDDIN MAKASSAR
I.

BIODATA
a. Identitas istri / ibu :
Nama
: ...................................................................
Umur
: ...................................................................
Suku / bangsa
: ...................................................................
Agama
: .....................................................................
Pendidikan terakhir
: ........................................................................
Pekerjaan
: ...........................................................
Penghasilan / bln
: ...................................................................
Status perkawinan
: ..................................................................
Lamanya
: ......................................................................
Perkawinan yang ke : .................................................................
Alamat
: ...................................................................
Tanggal kunjungan
: ...................................................................
b. Identitas Suami :
Nama
: ..................................................................
Umur
: ...................................................................
Suku / bangsa
: ...................................................................
Agama
: ....................................................................
Pendidikan terakhir
: ...................................................................
Pekerjaan
: ...............................................................
Penghasilan / bln
: .................................................................
Status perkawinan
: ..................................................................
Lamanya
: ...................................................................

II.

Perkawinan yang ke
Alamat

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

DATA BIOLOGIS / FISIOLOGIS


a. Keluhan utama : .......................................................................................
b. Riwayat keluhan utama : ........................................................................
c. Riwayat kehamilan sekarang :
G : ..................... P : ...................... A : .....................................
tafsiran persalinan ...................................................................
Jam berapa uterus mulai berkontraksi : .................................
Kontraksi His ...............................................
Interval His .................................................

d. Riwayat kehamilan dan persalinan serta nifas yang lalu

N
o

Kehamilan
Umu Keadaa
r
n

Thn

Persalinan
Tempa Penolon
t
g

Jeni
s

e. Pola Reproduksi :
Menarche umur ......................................
Sikluis haid ............................................
teratur /tidak .........................................

P/L

Anak
Lamany Keadaa
a
n skrg
menyus
ui

Riwaya
t Nifas

Lamanya haid .........................................


Sifat darah .............................................
Dysmenorhoe .......................................
f. Riwayat kesehatan
Riwayat penyakit yang pernah dialami / terutama yang berpengaruh
terhadap kehamilan ..........................................................................
Riwayat operasi yang pernah dialami .............................................
Riwayat keluhan ;
a. Penyakit : TBC, hepatitis, kejiwaan, malaria, DM atau penyalit
lainnya ..................................................................................
b. Kehamilan kembar ...............................................................
g. Pola kegiatan sehari-hari
1. Nutrisi :
Jenis makanan ............................................................................
Frekuensi makanan sehari .........................................................
Nafsu makan .............................................................................
Makanan pantang ....................................................................
Makanan kesukaan ..................................................................
Banyaknya minum sehari..........................................................
2. Eliminasi :
b. Buang air besar :
Frekuensi...............................................
Warna ...................................................
Konsistensi .........................................
c. Buang air kecil :
Frekuensi ............................................
Warna .................................................
Jumlahnya ..........................................
3. Istirahat (tidur) :
Tidur waktu malam berapa jam (dari pukul ............s/d.............)
Tidur waktu siang berapa jam ( dari pukul ............s/d .............)
4. Kebersihan diri :
Penampilan umum .....................................................................
Mandi / hari ...............................................................................
Sikat gigi / hari ..........................................................................
Cuci rambut / minggu ...............................................................
Ganti pakaian dalam dan luar sehari .........................................
5. Rekreasi / olah raga atau
hobby ;............................................................................ :....................
.........................................................................................
6. Ketergantungan :
Obat ....................................................................
Rokok .................................................................
Minuman keras ...................................................
7. Hubungan seksual, keluhan :.............................................................

8. Riwayat Keluarga Berencana : ..........................................................


Mengerti tentang KB ..................................................................
Setuju tentang KB .......................................................................
Pernah menjadi akseptor ...........................................................
Drop out, alasannya ...................................................................
h. Pemeriksaan fisik
a. Tanda-tanda vital :
Tekanan darah ................................mmHg
Suhu ............................. oC
Pernafasan ................../menit
Nadi ............................/ menit
b. Berat badan ......................Tinggi badan ..............................
c. Cara berjalan ........................................................................
d. Kesadaran umum .................................................................
e. Inspeksi :
1. Kepala
- Rambut ...................................................................
2. Muka
- Pucat
: ................................................
- Kloasma gravidarum : .................................................
- Sianosis
: .....................................................
- Udema
: .....................................................
3. Mata
- Kelopak mata : ......................................................
- Skelera mata
: .....................................................
- Konjungtiva
: .....................................................
4. Mulut dan gigi
- Berbau
: .................................
- kebersihan
: ................................
- Jumlah gigi
: ................................
- Caries
: ................................................
- Stomatitis
: ................................................
5. Leher
- Pembesaran kelenjar : ................................................
6. Buah dada
- Bentuknya
: ................................... ......................
- kebersihan
: .........................................................
- Keadaan puting susu : .........................................................
- Pengeluaran kolestrum: .......................................................
7. Perut
- Bentuknya
: ................................................................
- linea/strias
: .................................................................
- Bakas luka operasi : .............................................................
8. Vulva
- Udema
: .......................................................
- tanda chadwick
: ......................................................
- Pengeluaran darah lendir dari vagina
: .........................

- Kebersihan
: .......................................................
9. Tungkai
- Varises : .................................................................................
- Udema : ..................................................................................
- simetris : .................................................................................
f. Pemeriksaan panggul luar dan perut
1. Lingkar panggul
: ......................................................................
2. Lingkar perut : .....................................................................
3. Distensia cristarum : .....................................................................
4. Boudologue
: .....................................................................
g. Palpasi :
1. Tinggi Fundus Uteri
: ..........................................................
2. Punggung janin
: ...................................................................
3. Bagian terdepan
: ...................................................................
4. Turunnya bagian terdepan : .......................................................
h. Auskultasi :
1. Bunyi jantung janin : ..................................................................
2. Frekuensi
: ....................................................
................
3. Lokasi paling jelas
: .........................................................
...........
4. Gerak janin
: .........................................................
...........
5. Bunyi jantung ibu
: .........................................................
...........
i. Perkusi :
- Refleks patella
: Kanan
.....................kiri ................................
j. Pemeriksaan laboratorium
1. Urine :
- Albumin
:.......................................................................
2. Darah :
- Golongan darah:......................................................................
- HB
:......................................................................
k. Pemeriksaan rontgen : ....................................................................
III.

RIWAYAT PERSALINAN SEKARANG


a. Kala I
1. Lamanya
:
.................jam ...................menit
2. Tanda Vital
- Tekanan darah
: ............................
- Nadi
: .............................
- Pernafasan
: ..................................

3. Palpasi menurut Leopold :


- TFU
:
- Punggung janin
:
- Bagian yang terdepan
- Turunnya bagian terendah
4. His (kontraksi uteri )
- Tanggal
:
- Frekuensi
:
- lamanya
:
- Intensitas (kekuatannya :
5. Vaginal toucher :
- Dilakukan oleh
:
- Indikasi
:
- Tanggal
:
- Pembukaan
:
- Serviks
:
- Ketuban
:
- Bagian paling bawah
:
- Kesan panggul
:

.....................................................
.....................................................
: ...........................................
: ...........................................
......................jam .................menit
.................................
................................
.................................
.................................................
.................................................
.................................................
.................................................
.................................................
.................................................
.................................................
.................................................

b. Kala II
1. Lamanya
: .................jam ...................menit
2. His intensitasnya
: ..........................................................
3. Denyut Jantung Janin (DJJ)
: frekuensi ...........jumlahnya ..............
- Bagian paling depan
: .....................presentasio ..................
- Pelepasan lendir
: ...........................................................
- Ketuban pecah
: ........................................................
Warnanya
: ...........................................................
baunya
: ..........................................................
jumlahnya
: ............................................................
Keadaan His
: ...........................................................
keadaan perineum
:
............................................................
Ibu mulai mengedan
: ...........................................................
caranya mengedan
:..........................................
.................
Bayi lahir tanggal
:
................................jam ....................
Jenis persalinan
: ..........................................................
Perdarahan
: .........................................
.................
4. Keadaan bayi:
- Apgar skor
: 1 menit setelah
lahir : ...........................

Apgar skor
: 5 menit setelah
lahir :............................
Berat badan lahir
: ..........................gram
panjang badan
:.... ......................cm
Cacat bawaan
: ............................................................
Setelah 5 menit lahir apakah ada
mekonium : ..................................

c. Kala III
1. Lamanya
............menit
2. TFU setelah bayi lahir
3. Katerisasi urine
4. Lahirnya placenta
5. Pemeriksaan placenta
- Beratnya
.....................
- Tali pusat
Panjang
Keadaan
- Tanda Vital
Tekanan darah
Nadi
menit
Pernafasan
Suhu
- Perdarahan
....................
IV.

V.

: .........................................
: .............................................................
: ..............................................................
: ..............................................................
:
: .........................................
:
: ....................cm
: ...............................
Ibu

:
: .......................mmHg
: ......................./
: ....................../ menit
: .....................oC
: .........................................

DATA PSIKOLOGIS
1. Pola interaksi ..........................................................................................
2. Reaksi dan persepsi terhadap kehamilan ..............................................
- Direncanakan ...................................................................................
- Apakah klien cemas dengan persalinannya ........................................
- Jenis kelamin yang diharapkan ............................................................
- Bantuan pelayanan yang diharapkan ...................................................
- Kebutuhan kesehatan yang diharapakan ..............................................
Perawatan payudara agar ASI cukup untuk kebutuhan bayi
Bimbingan tentang perawatan bayi
- Pelayanan yang telah
diberikan :............................................................................. ................
..............................................................................................................
..............................................................................................................
......................................................
DATA SOSIAL

1.
2.
3.
4.
5.
VI.

Bagaimana hubungan terhadap keluarga .............................................


Bagaimana hubungan terhadap tetangga / masyararat ........................
Bagaiman hubungan dengan pasien yang di rawat di rumah sakit ........
Siapa yang paling terpenting bagi pasien ..............................................
Siapa yang menanggung perawatan .....................................................

DATA SPRITUAL
1. Keyakinan kepada Tuhan YME
2. Ketaatan dalam melaksanakan ibadah sekarang
Makassar, ............................2014
Mahasiswa yang bersangkutan,

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