LAPORAN RESUME MATERNITAS

PADA PERIODE ANTENATAL

Pengkajian
Nama Mahasiswa :
NIM :
Tempat Praktek : IGD Ponek RSUD H. Moch. Ansari Saleh
Tanggal Praktek :
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 utama 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 :
HPMT : 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 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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Inspeksi hidung :
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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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Jantung
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 perifer
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
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Banjarmasin, April 2018

NIM.