YAYASAN MARANATHA WILAYAH NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA KUPANG

Jln. Kamp. Bajawa Nasipanaf - Baumata Barat - Kab. Kupang

FORMAT PENGKAJIAN ASKEP PADA IBU ANTENATAL

Nama mahasiswa :
NIM :
Tanggal pengkajian :
Jam :
No.RM :
Tanggal masuk :

1. IDENTITAS
Nama pasien : Nama suami :
Umur : Umur :
Agama : Agama :
Suku/bangsa : suku/bangsa :
Pendidikan : pendidikan :
Pekerjaan : pekerjaan :
Alamat : Alamat :
2. KELUHAN UTAMA

3. RIWAYAT HAID
 Menarche umur :
 Siklus :
 Dismenore :
4. RIWAYAT PERNIKAHAN
 Status pernikahan :
 Nikah : kali
 Dengan suami sekarang : tahun
 Usia pertama kali nikah : tahun
5. RIWAYAT KEHAMILAN, PERSALINAN, NIFAS DAN ANAK YANG LALU
Ke- Masalah Tgl/Th Usia Jenis Penolong Penyulit Jenis BB/ PB Masalah
hamilan selama partus ke- partus partus selama kelamin selama laktasi KB
no kehamilan hamilan partus nifas
6. RIWAYAT KESEHATAN YANG LALU
 Penyakit/operasi yang pernah dialami :.....................................................................................
 Perawatan di .............................................................................................................................

7. RIWAYAT KESEHATAN KELUARGA

 Keturunan kembar : Ya / tidak
 Penyakit keturunan/menular : DM/TB/PJK/HT/HB/.............................................................

8. RIWAYAT KEHAMILAN SEKARANG ( G.....Ab.......P..... H.......... mgg)

 HPHT :
 Taksiran persalinan :
 BB sebelum hamil :
 TB sebelum hamil :
 Keadaan saat pemeriksaan sekarang
BB/TB TFU Letak/presentasi DJJ Usia gestasi keluhan Data lain
janin
  Gerakan janin :
 Tanda-tanda bahaya/penyulit :
 Perawatan ANC berapa kali : di
 Imunisasi TT :

9. KEBERSIHAN DIRI
 Pemeliharaan badan :
 Pemeliharaan gigi dan mulut :
 Perawatan vulva :

10. POLA AKTIVITAS SEHARI-HARI

a. Eliminasi
 BAK :
 BAB :

b. Nutrisi
 Pola makan :
 Minum :
c. Istirahat
 Tidur siang :
 Tidur malam :
d. seksualitas

11. KEADAAN PSIKOSOSIAL

 Persepsi ibu dan keluarga dengan kehamilan ini

 Persepsi ibu tentang pemberian ASI

 Persepsi ibu dan keluarga tentang kehadiran anggota keluarga baru

 Persepsi ibu tentang proses kelahiran

 Dukungan keluarga

12. PERILAKU KESEHATAN

 Kebiasaan merokok/minuman keras

 Kebiasaan minum jamu

 Kebiasaan ganti pakaian dalam

13. PEMERIKSAAN FISIK
a. keadaan umum

b. TTV
 suhu :...........................................(aksila/oral/rectal)
 Nadi :...........................................(reguler/irreguler)
 Pernafasan :...........................................(reguler/irreguler, dalam/dangkal)
 TD : .............................................
c. kepala
 kebersihan : ........................................................................................................................
 wajah : ........................................................................................................................
 mata : sklera mata.....................................................................................................
konjungtiva.....................................................................................................
alat bantu ......................................................................................................
 hidung : kesimetrisan..................................................................................................
sekret.............................................................................................................
 mulut : kelembaban...................................................................................................
kebersihan mulut(gigi&lidah)........................................................................
karies dentis..................................................................................................
stomatitis.......................................................................................................
perdarahan gusi.............................................................................................
  telinga : kemampuan mendengar................................................................................
serumen.........................................................................................................
 lain-lain : ........................................................................................................................
d. leher
 pembesaran kelenjar tiroid : .....................................................................................................
 DVJ :....................................................................................................................................
 Lain-lain : ...................................................................................................................................
e. dada/thorak
 bentuk : ...........................................................................................................
 retraksi : ...........................................................................................................
 auskultasi paru : ...........................................................................................................
 auskultasi jantung : ............................................... ............................................................
 mammae :
bentuk : ...........................................................................................................
konsistensi : ............................................................................................................
keadaan puting susu : ...........................................................................................................
hiperpigmentasi areola/papila : .........................................................
pengeluaran kolostrum : ............................................................................................................
bendungan ASI : ...........................................................................................................
f. Abdomen
 inspeksi : linea alba : ..............................................................................................
linea nigra :..............................................................................................
striae livide : ..............................................................................................
striae albican : ..............................................................................................
bekas luka operasi :...............................................................................................
lain-lain :...............................................................................................
 palpasi : TFU : ...............................................................................................
massa lain : ..............................................................................................
leopold I : ..............................................................................................
leopold II : ...............................................................................................
leopold III : ..............................................................................................
leopold IV : ..............................................................................................
 Auskultasi : DJJ : ..................X/mnt (positif/negatif, reguler/irreguler)
BU : ..................X/mnt (positif/negatif, menurun/meningkat)
 Perkusi : ........................................................................................................................
 Panggul :D.Spinarum : .................................................................................
D.Cristarum :.................................................................................
Conjugata external : ................................................................................
Lingkaran pinggul : .................................................................................
 Genetalia :
Kebersihan vulva : ...........................................................................................................
 Varises : ...........................................................................................................
Hematoma : ...........................................................................................................
fluor albus : ...........................................................................................................
Odema : ............................................................................................................
Hemorroid : ...........................................................................................................
Lain-lain : ...........................................................................................................
g. ekstremitas
 Edema : ........................................................................................................................
 Varises :.........................................................................................................................
 Plegia : .........................................................................................................................
 Parese : .........................................................................................................................
 Refleks patela : .........................................................................................................................
 Lain-lain : ........................................................................................................................

14.PEMERIKSAAN PENUNJANG

15. PEMBERIAN TERAPI