ASUHAN KEPERAWATAN IBU HAMIL

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Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :

A. DATA SUBYEKTIF
1. IDENTITAS
Nama : Nama Suami :

Umur : Umur :

Agama : Agama :

Pendidikan : Pendidikan :

Pekerjaan : Pekerjaan :

Penghasilan : Penghasilan :

Alamat : Alamat :

No Reg :

Diagnosa Medis :

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2. KELUHAN
a. Saat MRS
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b. Saat Pengkajian (Keluhan Utama)

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 3. RIWAYAT KESEHATAN
3.1Penyakit yang lalu
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3.2Penyakit sekarang
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3.3Penyakit Keluarga
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4. RIWAYAT OBSTETRI / KEBIDANAN
4.1Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .......................................................
Menarche :.......................................................... Dismenorhea: ........................................................
Lama :.......................................................... Flour Albus : .......................................................
Banyak : ........................................................
Siklus :.........................................................

5. RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU

No Tgl/Bln/Th Usia Tempat Jenis Penolong Peny Anak Nifas Usia Hidup
JK BB PB
(Gravida n Kehamil Persalina Persalina ulit anak /Mati
) Persalinan an n n

6. RIWAYAT KEHAMILAN SEKARANG

6.1 Riwayat Kehamilan ini : G.....P......................Ab........................

 6.2 HPHT :................................ HPL :....................................

6.3 Usia Kehamilan:......................

6.4 Keluhan hamil

muda ......................................................................................................................................................

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6.5 Kapan terasa gerakan awal.....................................................................................................................

6.6 ANC.....................x, di............................................................................................................................

6.7 Status TT................................................................................................................................................

6.8 Terapi yang pernah diberikan.................................................................................................................

6.9 Penyuluhan yg pernah didapat

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7. RIWAYAT KB

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8. RIWAYAT PERNIKAHAN

Usia....................berapa kali.................................

Jarak perkawinan & kehamilan pertama................................................th

9. RIWAYAT PSIKOSOSIAL SPIRITUAL & KELUARGA

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10.POLA AKTIFITAS
Kebutuhan Dasar Sebelum Hamil Saat Hamil

1. Cairan &

Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

6. Pola Sexualitas

B. DATA OBJEKTIF

1. KEADAAN UMUM :

- Kesadaran :

- TTV :

- TB :

- BB (sebelum & saat hamil) :

- Lila :

2. PEMERIKSAAN FISIK

a. Pemeriksaan Kepala ( Inspeksi, Palpasi)

- Rambut :........................................................................................................................................

- Wajah :........................................................................................................................................

- Mata :........................................................................................................................................

- Hidung :........................................................................................................................................

- Mulut :........................................................................................................................................

- Telinga :........................................................................................................................................

b. Pemeriksaan Leher :........................................................................................................................................

c. Pemeriksaan Thorax (Inspeksi, Palpasi, Auskultasi)

- Payudara
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- Jantung

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- Paru

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a. Pemeriksaan Abdomen (Inspeksi, Palpasi, Auskultasi)

Inspeksi :......................................................................................................................................................

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Palpasi

- Leopold I :......................................................................................................................................................

TFU :........................cm

TBJ :.........................gr

- Leopold II :......................................................................................................................................................

DJJ :......................................................................................................................................................

- Leopold III :........................................................................................................................................

- Leopold IV :........................................................................................................................................

b. Pemeriksaan Panggul Luar

- Distansia Spinarum, : ..............................cm

- Distansia Cristarum, :..............................cm

- Boudloque (Lingkar Panggul) :......................................cm

c. Pemeriksaan Ekstremitas

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d. Pemeriksaan Genetalia

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 Pemeriksaan Dalam (Vaginal Toucher)

Dilakukan oleh.................................... Tanggal..................................

Jam.........................................................................

Hasil :.................................................................................................................................................

Pemeriksaan Integumen

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1. PEMERIKSAAN PENUNJANG

- Laboratorium/USG

- Radiologi

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2. TERAPI

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3. KESIMPULAN
 G….............P…................Ab……................Usia Kehamilan......................minggu

Janin......................................................................................................................................................................

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Keterangan:

4. ANALISA DATA

No Tanggal / Analisa Data Etiologi Masalah

Jam Keperawatan
5. DIAGNOSA KEPERAWATAN
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6. INTERVENSI

NO TANGGAL/JAM DIAGNOSA NOC NIC

KEPERAWATAN
7. IMPLEMENTASI

NO TANGGAL/JAM DIAGNOSA IMPLEMENTASI

KEPERAWATAN
8. EVALUASI

NO TANGGAL/JAM DIAGNOSA EVALUASI

KEPERAWATAN