FORMAT PENGKAJIAN ANTENATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

A. IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

B. STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
....................................................................................................................................
..........………………………………………………………………………………
………..…
2. Keluhan utama saat ini : ..................................................................……..................
....................................................................................................................................
..........………………………………………………………………………………
…….……
3. Riwayat kesehatan saat ini

4. Diagnosa medik : ...........................................................................……....................

C. RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :

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 b. Riwayat kehamilan, persalinan, nifas :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Usia anak Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan

c. Genogram :
2. RIWAYAT KELUARGA BERENCANA :
 Melaksanakan KB : ( ) ya ( ) tidak
 Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
 Sejak kapan menggunakan kontrasepsi : ................................................................
 Masalah yang terjadi : ............................................................................................

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 : ................................................................
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 : (SMRS DAN MRS)

a. Pola Nutrisi
 Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
 Jenis makanan rumah : ................................................................................….
 Makanan yang tidak disukai/ alergi/ pantangan : .............................................

b. Pola eliminasi :
 BAK
- Frekwensi : ....................kali
- Warna : .......................……………………………………………….
- Keluhan saat BAK : .................................................………......................

 BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : .............……………………………………………….........
- Keluhan : ..............................................................................………....

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 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

 Merokok :
..............................................................................................
 Minuman keras :
..............................................................................................
 Ketergantungan obat :
..............................................................................................

7. PEMERIKSAAN FISIK
 Keadaan umum : ......................................Kesadaran : .........................
 Tekanan darah : ......................................Nadi : .............x/menit
 Respirasi : ......................................Suhu : .......…........C
 Berat badan : ......................kg Tinggi badan : ................cm

Kepala, mata kuping, hidung dan tenggorokan :

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

Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
 Lainnya sebutkan : .................................................................................................

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Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................

Dada dan Axilla

 Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
 Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

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
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak
 Leopold I :
 Leopold II :
 Leopold III:
 Leopold IV:
 Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :

Genitourinary
 Perineum : ...............................................................................................
 Vesika Urinaria : ...............................................................................................
 Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
 Vagina : varises: ya/ tidak
 Kebersihan :
 Keputihan :
 Jenis/warna :

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

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8. Kesiapan dalam kehamilan dan persalinan:
a. Senam hamil
b. Rencana tempat melahirkan
c. Perlengkapan kebutuhan bayi dan ibu
d. Kesiapan mental ibu dan keluarga
e. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan

9. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................

10. Data Tambahan

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................
Surabaya, ........................................
Pemeriksa

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