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DEPARTEMEN PENDIDIKAN NASIONAL

PROGRAM PENDIDIKAN PROFESI NERS


UNIVERSITAS RESPATI YOGYAKARTA
FORMAT PENGKAJIAN ANTENATAL
UNIT KEPERAWATAN MATERNITAS
Tanggal masuk
Ruang/kelas
Pengkajian tanggal
Diagnosa Medis
1.
1.
2.
3.
4.
5.
6.
7.
8.

:
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

2. STATUS KESEHATAN SAAT INI


1. Alasan kunjungan ke rumah sakit : ....................................................
................
......................................................................................................................................
........
..

2. Keluhan utama saat ini : ..................................................................


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

3. Timbulnya keluhan : (
) bertahap, (
) mendadak
4. Faktor yang memperberat : ..........................................................
.....................
.............................................................................................................
...............................

Format pengkajian antenatal/universitas respati yogyakarta

..
.
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

Format pengkajian antenatal/universitas respati yogyakarta

b. Riwayat kehamilan, persalinan, nifas yang lalu :


Anak ke
Kehamilan
Persalinan
No

Tahun

Umur
kehamila
n

c. Genogram :

Penyulit

Jenis

Penolong

Komplikasi nifas
Penyulit

Laserasi

Infeksi

Perdaraha
n

Anak
Jenis

BB

pj

2. RIWAYAT KELUARGA BERENCANA :

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

Riwayat penyakit keluarga


( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya
: sebutkan ......................................................................
4. RIWAYAT LINGKUNGAN :
- Kebersihan :
...........................................................................................................
.......
- Bahaya
:
......................................................................................................................
- Lainnya sebutkan :
.................................................................................
.....................
5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. KEBUTUHAN DASAR KHUSUS :
a. Pola Nutrisi

Frekwensi makan : .............................. x sehari

Nafsu makan : ( ) baik, (


)
tidak
nafsu,
alasan ..........................................

Jenis makanan rumah : .................................................................................


Format pengkajian antenatal/universitas respati yogyakarta

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

Lama tidur : ............................jam/hari

Kebiasaan sebelum tidur : ................................................................................

Keluhan : ..........................................................................................................

e. Pola aktifitas dan latihan

Kegiatan dalam pekerjaan : ..............................................................................

Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam

Olah raga
: ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................

Kegiatan
waktu
luang : .....................................................................................

Keluhan dalam beraktifitas : ............................................................................


f. Pola kebiasaan yang mempengaruhi kesehatan

Format pengkajian antenatal/universitas respati yogyakarta

Merokok

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

Minuman
keras
: ..............................................................................................
Ketergantungan
: ..............................................................................................
Lainnya
:
..

obat

7. PEMERIKSAAN FISIK

Keadaan umum : ......................................Kesadaran : .........................

Tekanan darah
: ......................................Nadi
:
.............x/menit

Respirasi
: ......................................Suhu
: ...............C

Berat badan
: ......................kg
Tinggi badan :
................cm

LILA
:
Pelvimetri
Distansia Spinarum
Distansi Cristarum
Konjugata eksterna
Lingkar Panggul

:
:
:
:

Kepala, mata kuping, hidung dan tenggorokan :


Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :

Kelopak
mata : .....................................................................................................

Gerakan
mata : ....................................................................................................

Konjungtiva
: ..............................................................................................
.......

Sklera
: .............................................................................................
.......

Pupil
: ...............................................................................................
......

Akomodasi
: ...............................................................................................
......

Lainnya
sebutkan : .................................................................................................
Hidung :

Reaksi
alergi : .....................................................................................................

Format pengkajian antenatal/universitas respati yogyakarta

Sinus

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

.......
Lainnya
sebutkan : .................................................................................................
Mulut dan Tenggorokan :

Gigi
geligi
: .....................................................................................................

Kesulitan
menelan : ................................................................................................

Lainnya
sebutkan : .................................................................................................
Dada dan Axilla

Mammae : membesar ( ) ya ( ) tidak

Areolla
mammae : ..................................................................................................

Puting :

Pernafasan

Jalan
nafas
: .....................................................................................................

Suara
nafas
: ....................................................................................................

Menggunakan
otot-otot
bantu
pernafasan : ............................................................

Lainnya
sebutkan : .................................................................................................
Sirkulasi jantung

Kecepatan denyut apical : ...............................x/menit

Irama
: .........................................................................................
......

Kelainan
bunyi
jantung : ........................................................................................

Sakit
dada
: ...............................................................................................

Timbul
.: .........................................................................................
......

Lainnya
sebutkan : ..............................................................................................

Abdomen

Linea
dan
striae : ...............................................................................................

Kontraksi
: ...........................................................................................
.....
Format pengkajian antenatal/universitas respati yogyakarta

Hasil Pemeriksaan LEOPOLD :


Leopold 1 :

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

Format pengkajian antenatal/universitas respati yogyakarta

Yogyakarta, ........................................
Pemeriksa

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

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