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LAPORAN RESUME

Pengkajian
Nama Mahasiswa : Anisa Rahmawati, S.Kep
NIM : 1730913320021
Tempat Praktek : IGD Kandungan RSUD Dr. H. Moch. Ansari Saleh
Tanggal Praktek : 21 - 25 Maret 2016

Data Demografi
Nama Klien : Nama Suami :
Umur Klien : Umur Suami :
Jenis Kelamin : Alamat :
Status Perkawinan : Pekerjaan :
Agama : Diagnosa Medik :
Suku : Tgl MRS :
Pendidikan : Tgl Pengkajian :

Keluhan saat ini :


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Riwayat penyakit dahulu :


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Riwayat penyakit keluarga :


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Riwayat Ginekologi :
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Riwayat Obstetri :
G P A HPL :
HPHT : Usia Kehamilan :
Keluhan yang muncul selama kehamilan :
1. Trimester I :
2. Trimester II :
3. Trimester III :

Kebiasaan yang merugikan :


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Kebutuhan Dasar sehari hari


Nutrisi
Pola makan frekuensi, jenis dan jumlah :
Alergi makanan :
Minuman jumlah dan jenis :
Keluhan yang berhubungan dengan nutrisi :

Eliminasi
BAK :
BAB :
Aktivitas dan latihan :
Aktivitas selama hamil :
Keluhan dalam beraktivitas :

Istirahat dan tidur


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Seksualitas
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Persepsi dan kognitif


Status mental :
Sensasi :
- Pendengaran : - Perabaan :
- Berbicara : - Kejang :
- Penciuman : - Nyeri :

Persepsi diri dan konsep diri


Motivasi terhadap kehamilan :
Efek kehamilan terhadap body image :
Orang paling dekat :
Tujuan dari kehamilan :

Keluarga Berencana
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Pemeriksaan Fisik
Kaji vital sign
Tekanan darah : mmHg
Nadi : x/menit
Temperatur : C
Respirasi rate : x/menit
Ukur BB dan TB : kg dan cm

Inspeksi Kulit
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Inspeksi kuku dan rambut
Kepala dan leher
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Telinga
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Mulut, tenggorokan dan hidung


Inspeksi mulut :
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Inspeksi tenggorokan :
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Thoraks dan paru-paru
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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Payudara
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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Abdomen
Inspeksi :
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Palpasi :
Leopold I................................................................................................
Leopold II...............................................................................................
Leopold III.............................................................................................
Leopold IV.............................................................................................
Tinggi Fundus Uteri :
Auskultasi :
(Frekuensi, kekuatan, kesimpulan)
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Tafsiran berat janin :

Genitalia
Inspeksi :
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Palpasi :
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Anus dan rektum


Inspeksi :
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Vaskularisasi perifir
Inspeksi :
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Perkusi reflex tendon


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Muskuloskeletal
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Neurologik
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Data Laboratorium
Tanggal dan Hasil pemeriksaan dan nilai normal Interpretasi
jenis
pemeriksaan
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Pengobatan
Tanggal Jenis terapi Rute terapi Dosis Indikasi terapi
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Analisa Data
Data Kemungkinan Penyebab Masalah
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Diagnosa Keperawatan
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Rencana, Implementasi, Evaluasi
Tanggal Diagnosa
Tujuan Intervensi Implementasi Evaluasi
/ Jam Keperawatan

Banjarmasin,.. 2017

Anisa Rahmawati, S.Kep


NIM 1730913320021