FORMAT ASUHAN KEPERAWATAN ANTENATAL

ASUHAN KEPERAWATAN PADA Ny..................

DENGAN.........................................
DI RUANG..........................
RS..
TANGGAL.................

I. PENGKAJIAN

.A IDENTITAS PASIEN PENANGGUNG/ SUAMI

Nama : .............................. Nama : ...........................
Umur : .............................. Umur : .
Pendidikan : ............................. Pendidikan :
Pekerjaan : ............................. Pekerjaan : ........................
Status perkawinan : ............................. Alamat : ............................
Agama : ............................
Suku : .............................
Alamat : .............................
No. CM : .............................
Tangal MRS : ............................
Tanggal Pengkajian : ............................
Sumber informasi : ............................

.B ALASAN KUNJUNGAN
.1 Keluhan Utama/Alasan ke Poliklinik
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.2 Keluhan saat dikaji (jika ada)

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.C RIWAYAT OBSTERTRI DAN GINEKOLOGI

.a Riwayat Menstruasi :
Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
Banyaknya : .................... Lamanya :..................................
Keluhan : .................................................................
HPHT : .................................................................

.b Riwayat Pernikahan :
Menikah : ....................kali Lama : ................. tahun.
 .c Riwayat kelahiran, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

N Tahun Umur Penyu Jen Penolo Penyu Laser Infe Pedarah Jenis BB Pj
o kehamil lit is ng lit asi ksi an kelam
an in

.d Riwayat kehamilan saat ini

Status Obstetrikus:
G..............P............A...............H UK :.................minggu............hari
TP:..............................
ANC kehamilan sekarang : ............................................................................
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.e Riwayat Keluarga Berencana :

Akseptor KB : jenis .............. Lama : ..................
Masalah : .................................................
Rencana KB : .................................................

.D RIWAYAT PENYAKIT
1. Klien : ..............................................................................................................
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2. Keluarga : ........................................................................................................
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E. POLA FUNGSIONAL KESEHATAN

1. Pola Manajemen Kesehatan-Persepsi Kesehatan









2. Pola Metabolik-Nutrisi

3. Pola Eleminasi

4. Pola Aktivitas-Latihan

5. Pola Istirahat-Tidur

6. Pola Persepsi-Kognitif

7. Pola Konsep Diri-Persepsi Diri

8. Pola Hubungan-Peran





9. Pola Reproduktif-Seksualitas

10. Pola Toleransi Terhadap Stres-Koping

11. Pola Keyakinan-Nilai

F. PEMERIKSAAN FISIK
Keadaan umum
- GCS : ......................................
- Tingkat kesadaran : ......................................
- Tanda-tanda fital : TD ............. N .............
RR .............. T ...............
- BB : ................... TB : ............... LILA : ........

Head toe toe :

Kepala : ..
Wajah :...........................................................................
Pucat ( )
Cloasma ( )
Sklera :...........................................................................
Konjungtiva : :...........................................................................
Pembesaran limphe node :............................................................................
Pembesaran kelenjar tiroid :...........................................................................

telinga : .

Dada
Payudara
 Areola: .. Puting : (menonjol / tidak )
Tanda dimpling / retraksi :.
Pengeluaran ASI : ..
Jantung : ......



Paru : ..

Abdomen :
o Linea : ..............................................................................................
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o Striae : ..............................................................................................
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o Pembesaran sesuai UK : ..........................................................................
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o Gerakan Janin :.........................................................................................
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o Kontraksi : ..............................................................................................
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o Luka SC : ..............................................................................................
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o Ballottement : ..................................................................................
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Leopold I : Kepala / bokong / kosong TFU:.............
Leopold II:
Kanan : punggung/bagian kecil/bokong /kepala
Kiri : punggung / bagian kecil /bokong/kepala
Leopold III : Presentasi kepala / bokong/kosong
Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar)
Penurunan kepala : .........
(penurunan bag.terbawah dengan metode lima jari )
Kontraksi : .
DJJ :..
o Bising usus : .................
o Diastasi rectus abdominis : ......................................

Genetalia
o Kebersihan : ......................................
 o Lokhea : ............................... Krakteristik : ..........................
o Keputihan : ...............................
Perineum dan anus
o Perineum : REEDA .......................
o Hemoroid : ......................................

Ekstremitas :
Atas : ......................................
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Bawah
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Tanda homan : ......................................
Pemeriksaan Reflek : ......................................
 G. DATA PENUNJANG
Pemeriksaan Laboratorium
Tanggal.........................................
Nilai
Pemeriksaan Hasil Satuan Keterangan
Rujukan
 Pemeriksaan USG :
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H. DIAGNOSA MEDIS
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I. PENGOBATAN
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 A. ANALISA DATA
Data Fokus
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B. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS :
Analisis Masalah
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 II. RENCANA KEPERAWATAN
Rencana Keperawatan
No Nama
No Tgl/jam Tujuan &
Diagnosa Intervensi Rasional /TTD
Kriteria Hasil
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III. IMPLEMENTASI
No Tanggal/ No Implementasi Evaluasi Nama/
Jam DX TTD

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IV. EVALUASI
No Tanggal/ jam
Diagnosa
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Nomor Evaluasi Nama/
TTD
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LEMBAR PENGESAHAN

Denpasar,..2017
Pembimbing Praktik/CI Mahasiswa

.. Dewa Gede Sastra Ananta Wijaya

NIP. NIM. P07120214005

Mengetahui,
Pembimbing Akademis / CT

..
NIP.