JURUSAN KEPERAWATAN

UNIVERSITAS BRAWIJAYA MALANG

DEPARTEMEN KEPERAWATAN MATERNITAS

PENGKAJIAN PRENATAL
Nama Mahasiswa: Tempat Praktik:
NIM : Tgl. Praktek :
DATA UMUM KLIEN
1. Initial Klien :....................................................................................................
2. Usia :...................................................................................................
3. Status Perkawinan :...................................................................................................
4. Pekerjaan :....................................................................................................
5. Pendidikan Terakhir :...................................................................................................

Riwayat Kehamilan dan Persalinan Yang Lalu

No Tahun Jenis Persalinan Penolong Jenis Keadaan Bayi Waktu Lahir Masalah Kehamilan
1
2
3
4
5
Pengalaman menyusui: ya/tidak Berapa lama:..........................................

Riwayat Ginekology: Menarchea........................................Dismenorhea:.........................................

Riwayat KB:..........................................................................
Riwayat Kehamilan Saat Ini
HPHT:...................................................................................Taksiran Partus:.....................................
BB sebelum hamil:................................................................TD sebelum
hamil:..................................
TD BB/TB Letak/Presentasi Janin DJJ Usia Gestasi Keluhan Data Lain

DATA UMUM KESEHATAN SAAT INI

Status Obstetrik: G......P...........Ab...........H........ Minggu:..................................................
Keadaan Umum:.................................Kesadaran:......................BB/TB..............Kg/.....................Cm
Tanda Vital:
TD:............................mmHg Suhu:............oC
Nadi:..............................x/menit Pernafasan:............x/menit
Kepala Leher

Kepala:......................................................................................................................................

Mata:.........................................................................................................................................

Hidung:......................................................................................................................................
Mulut:........................................................................................................................................

Telinga:......................................................................................................................................

Leher:........................................................................................................................................
Masalah
Khusus:.......................................................................................................................
Dada
Jantung:....................................................................................................................................
.
Paru :.......................................................................................................................................
Payudara:.................................................................................................................................
.
Putting
Susu:.............................................................................................................................
Pengeluaran
ASI:......................................................................................................................
Masalah
Khusus:.......................................................................................................................
Abdomen
Uterus
Tinggi Fundus Uteri (TFU):.......................................................Cm Kontraksi: ya/tidak
Leopold I : kepala/bokong/kosong
Leopold II : Kanan: punggung/bagian kecil/bokong/kepala
Kiri: punggung/bagian kecil/bokong/kepala
Leopold III : kepala/bokong/kosong
Leopold IV : bagian masuk PAP
Pigmentasi:
Linea Nigra
 Striae
Fungsi Pencernaan:.................................................................................................................
Masalah Khusus:......................................................................................................................
..........................................................................................................................
Perineum dan Genital
Vagina: varises ya/tidak
Kebersihan: .............................................................................................................................
Keputihan:
Jenis/warna:.......................................................................................................................
.
Konsistensi:........................................................................................................................
Bau:....................................................................................................................................
.
Hemorrhoid: derajat:...................lokasi:....................berapa lama...........................nyeri/tidak
Masalah Khusus:......................................................................................................................
..........................................................................................................................
Ekstremita
Ekstremitas Atas
Edema: ya/tidk, lokasi:.....................................................
Varises: ya/tidak, lokasi...................................................
Ekstremitas Bawah
Edema: ya/tidk, lokasi:.....................................................
Varises: ya/tidak, lokasi...................................................
Refleks Patela: +/-, jika ada +1, +2, +3, +4
Eliminasi
Urine: kebiasaan BAK..............................................................................................................
BAB: kebiasaan BAB................................................................................................................
Istirahat dan Kenyamanan
Pola Tidur: kebiasaan tidur, lama...........jam............frekuensi.......pola tidur saat ini................
Keluhan ketidaknyamanan: ya/tidak, lokasi...........................sifat....................intensitas.........
Mobilisasi dan Latihan
Tingkat Mobilisasi:....................................................................................................................
Latihan/Senam:........................................................................................................................
Masalah Khusus:......................................................................................................................
Nutrisi dan Cairan
Asupan Nutrisi:..............................Nafsu makan: baik/kurang/tidak ada
Asupan Cairan:.............................cukup/kurang
Masalah Khusus:......................................................................................................................
..........................................................................................................................
Keadaan Mental
 Adaptasi
Psikologis:..................................................................................................................
Penerimaan terhadap
kehamilan:.............................................................................................
Masalah
Khusus:.......................................................................................................................
Pola hidup yang meningkatkan resiko kehamilan:...............................................................................
o Persiapan persalinan
o Senam hamil
o Rencana tempat melahirkan
o Perlengkapan kebutuhan bayi dan ibu
o Kesiapan mental ibu dan keluarga
o Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses
persalinan
o Perawatan payudara
Obat-obatan yang dipakai saat
ini:.......................................................................................................
Hasil pemeriksaan penunjang:.............................................................................................................
.............................................................................................................................................................
.
RANGKUMAN HASIL PENGKAJIAN
Masalah:..............................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
..
Rencana kunjungan
rumah:..................................................................................................................