:
Jam masuk
:
:
Kamar No
:
:
Jam
:
:.
IDENTITAS
Nama pasien : .................................
.....................
Umur
: ....................... th
: ....................... th
Suku/ bangsa : .................................
...................
Agama
: .................................
: ...........................
Pendidikan
: ..................................
: ...........................
Pekerjaan
: ..................................
: ...........................
Alamat
: ..................................
: ...........................
Status ..................................................
Nama Suami :
Umur
Suku/ bangsa :
Agama
Pendidikan
Pekerjaan
Alamat
3. Timbulnya keluhan : (
) bertahap, (
) mendadak
4. Faktor yang memperberat : ..........................................................
.....................
.............................................................................................................
...............................
..
.
5. Upaya yang dilakukan untuk mengatasi : ................................
.........................
......................................................................................................................................
......
...
6. Diagnosa medik : ...........................................................................
....................
3.
RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
Menarche
: umur....................
tidak ( )
Banyaknya
: ............................
: ...........................
HPHT
: ............................
: ...........................
Siklus
: teratur (
Lamanya
Keluhan
Tahun
Umur
kehamila
n
c. Genogram :
Penyulit
Jenis
Penolong
Komplikasi nifas
Penyulit
Laserasi
Infeksi
Perdaraha
n
Anak
Jenis
BB
pj
Melaksanakan KB : ( ) ya ( ) tidak
Bila
ya
jenis
kontrasepsi
digunakan : ......................................................
Sejak
kapan
kontrasepsi : ................................................................
Masalah
terjadi : ............................................................................................
apa
yang
menggunakan
yang
3. RIWAYAT KESEHATAN :
Penyakit
yang
pernah
dialami
ibu : ........................................................................
Pengobatan
yang
didapat : ......................................................................................
Makanan
yang
tidak
pantangan : .............................................
disukai/
alergi/
b. Pola eliminasi :
B AK
Frekwensi : ....................kali
Warna
:
.......................
.
Keluhan saat BAK : .................................................
......................
B AB
- Frekwensi : ....................kali
- Warna
: ..........................
- Bau
: ..........................
Konsistensi
:
.............
.........
Keluhan
: ..............................................................................
....
c. Pola personal hygiene
Mandi
- Frekwensi : ...................................x /hari
- Sabun
: ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
- Waktu
: ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
- Shampo
: ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Keluhan : ..........................................................................................................
Olah raga
: ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan
waktu
luang : .....................................................................................
Merokok
: .............................................................................................
Minuman
keras
: ..............................................................................................
Ketergantungan
: ..............................................................................................
Lainnya
:
..
obat
7. PEMERIKSAAN FISIK
Tekanan darah
: ......................................Nadi
:
.............x/menit
Respirasi
: ......................................Suhu
: ...............C
Berat badan
: ......................kg
Tinggi badan :
................cm
LILA
:
Pelvimetri
Distansia Spinarum
Distansi Cristarum
Konjugata eksterna
Lingkar Panggul
:
:
:
:
Kelopak
mata : .....................................................................................................
Gerakan
mata : ....................................................................................................
Konjungtiva
: ..............................................................................................
.......
Sklera
: .............................................................................................
.......
Pupil
: ...............................................................................................
......
Akomodasi
: ...............................................................................................
......
Lainnya
sebutkan : .................................................................................................
Hidung :
Reaksi
alergi : .....................................................................................................
Sinus
: .............................................................................................
.......
Lainnya
sebutkan : .................................................................................................
Mulut dan Tenggorokan :
Gigi
geligi
: .....................................................................................................
Kesulitan
menelan : ................................................................................................
Lainnya
sebutkan : .................................................................................................
Dada dan Axilla
Areolla
mammae : ..................................................................................................
Puting :
Pernafasan
Jalan
nafas
: .....................................................................................................
Suara
nafas
: ....................................................................................................
Menggunakan
otot-otot
bantu
pernafasan : ............................................................
Lainnya
sebutkan : .................................................................................................
Sirkulasi jantung
Irama
: .........................................................................................
......
Kelainan
bunyi
jantung : ........................................................................................
Sakit
dada
: ...............................................................................................
Timbul
.: .........................................................................................
......
Lainnya
sebutkan : ..............................................................................................
Abdomen
Linea
dan
striae : ...............................................................................................
Kontraksi
: ...........................................................................................
.....
Format pengkajian antenatal/universitas respati yogyakarta
Leopold 2 :
.
Leopold 3 :
.
Leopold 4 :
..
Lainnya
sebutkan : ................................................................................................
Genitourinary
Perineum
: ...............................................................................................
Hemoroid
: ..
Vesika Urinaria : ...............................................................................................
Kebersihan
: ..
Lainnya sebutkan : ...............................................................................................
Ekstrimitas (integumen/muskuloskeletal)
Turgor kulit : ................................................
Warna kulit : .................................................................................................
Kontraktur pada persendian ekstrimitas : .........................................................
Varises
:..
Edema tungkai:.
Reflek patella :.
Kesulitan dalam pergerakan : .........................................................................
Lainnya sebutkan : ...........................................................................................
8. Data Penunjang
1)
Laboratorium : .............................................................................................
....
2)
USG
: .................................................................................................
3)
Rontgen
: .............................................................................................
....
4)
Terapi yang
didapat: ......................................................................................................................
....................................................................................................................................
..............
9. Data Tambahan
............................................................................................................................................
............................................................................................................................................
Yogyakarta, ........................................
Pemeriksa
(..................................................)
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