FORMAT PENGKAJIAN PRENATAL

Nama Mahasiswa : …………………...................................................

Tanggal Pengkajian : …………………...................................................
NPM : …………………...................................................
Ruangan/RS : …………….........................................................

DATA UMUM KLIEN

1. Initial Klien
2. Usia
3. Status Perkawinan
4. Pekerjaan
5. Pendidikan Terakhir
: ...................................................................
: ...................................................................
: ...................................................................
: ...................................................................
: ...................................................................

Riwayat Kehamilan dan Persalinan yang lalu

Jenis Keadaan Bayi Masalah
No. Tahun Penolong Jenis
Persalinan Waktu Lahir Kehamilan

Pengalaman menyusui : Ya/Tidak Berapa lama : …………

Riwayat Ginekologi :
1. Masalah Ginekologi
2. Riwayat KB

Riwayat Kehamilan Saat Ini

HPHT : …………………… Taksiran Partus : …………………..
BB sebelum hamil : …………………. TD sebelum hamil : ……………...

T Letak/Presentasi DJ Usia Data

BB/TD TFU Keluhan
D Janin J Gestasi Lain

DATA UMUM KESEHATAN SAAT INI

Status Obstetrik : G… P…A… H… Minggu
Keadaan Umum : …….... Kesadaran : …………... BB/TB : …….. Kg/……..cm
Tanda Vital :Tekanan Darah : ……….. mmHg ; Nadi ……….. Suhu : …..OC
Pernapasan : ………… x/menit

0
Kepala Leher :

Kepala : ................................................................................................................
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Mata : ...............................................................................................................
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Hidung : ................................................................................................................
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Mulut : ................................................................................................................
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Telinga : ................................................................................................................
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Leher :
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Masalah khusus : ...........................................................................................

Dada :
Jantung : ................................................................................................................
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Paru : ................................................................................................................
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Payudara : ................................................................................................................
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Puting susu : ..........................................................................................
PengeluaranASI : ..........................................................................................
Masalah Khusus : ..........................................................................................
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Abdomen.
Uterus :Tinggi fundus uterus : ………...cm Kontraksi : Ya/Tidak
Leopold I : Kepala/Bokong/Kosong
Leopold II : Kanan ; punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/kepala
Leopold III : Kepala/Bokong/Kosong
Penurunan kepala ; sudah/belum
Leopold IV : bagian masuk PAP
Pigmentasi : Linea nigra : ya / tidak , Striae : ya / tidak
Fungsi Pencernaan : ........................................................................................
Masalah Khusus : ..........................................................................................

Perineum dan genital.

Vagina : Varises ; Ya/Tidak
Kebersihan : .........................................................................................................
Keputihan : ...........................................................................................................
Jenis/Warna : .................................................................................................
Konsistensi : .................................................................................................
Bau : ..........................................................................................
Hemorrhoid : ………….. Derajat ……….. Lokasi ………… Berapa lama ………….. Nyeri :
Ya/Tidak
Masalah Khusus : ......................................................................................
Ekstremitas.
Ekstremitas Atas :
Edema : Ya/ Tidak, lokasi …………………………...........................................................
Varises : Ya / Tidak, lokasi …………………………............................................................

Ekstremitas Bawah :
Edema : Ya / Tidak, lokasi …………………………....................................................
Varises : Ya / Tidak, lokasi …………………………....................................................
Refleks Patella : +/- Jika ada : +1/+2/+3/+4
Masalah Khusus : …………………………………………………………..........................

Eliminasi.
Urine : Kebiasaan BAK ………………………………….....................................................
BAB : Kebiasaan BAB ………………………………….....................................................
Masalah Khusus : …………………………………………………………..........................

Istirahat dan Kenyamanan.

Pola Tidur : Kebiasaan tidur, lama …… jam, frekuensi ………………………………..
Pola tidur saat ini ………………………………………….................................................
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Keluhan ketidaknyamanan : Ya/Tidak, lokasi ………………………................................
Sifat : …………………… Intensitas : ……………………………...................................

Mobilisasi dan Latihan :

Tingkat mobilisasi : ………………………….....................................................................
Latihan/senam : ……………………………………………............................................
Masalah Khusus : ……………………………………………............................................

Nutrisi dan Cairan :

Asupan Nutrisi : ………….. Nafsu makan : baik/kurang/tidak ada
Asupan Cairan : ………………………. Cukup/kurang
Masalah Khusus : ……………………………………………............................................

Keadaan Mental :
Adaptasi Psikologis : ………………………………………………......................................
Penerimaan terhadap kehamilan : ………………………………........................................
Masalah Khusus : ……………………………………………............................................
Pola hidup yang meningkatkan risiko kehamilan :
………………………………………………….....................................................................
………………………………………………….....................................................................
Persiapan Persalinan :
 Senam hamil
 Rencana tempat melahirkan
 Perlengkapan kebutuhan bayi dan ibu
 Kesiapan mental ibu dan keluarga
 Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses persalinan
 Perawatan payudara

Obat-obatan yang dikonsumsi saat ini : …………………………………….........................

Hasil Pemeriksaan Penunjang : ………………………………………………......................

RANGKUMAN HASIL PENGKAJIAN

Masalah: …………………………………………………………………………....................
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Perencanaan Kunjungan Rumah :

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 FORMAT PENGKAJIAN POST PARTUM

Nama Mahasiswa : ………………….. Tanggal pengkajian : …………………..

NPM : …………………... ruangan/RS : ………………….

DATA UMUM KLIEN

1. Inisial klien : Inisial Suami :
2. Usia : Usia :
3. Status Perkawinan : Status Perkawinan :
4. Pekerjaan : Pekerjaan :
5. Pendidikan Terakhir : Pendidikan Terakhir :

Riwayat Kehamilan dan Persalinan Yang Lalu

Keadaan
Tipe Jenis BB Bayi Masalah
No. Tahun Penolong
Persalinan Kelamin Lahir waktu Kehamilan
lahir
1
2
3
4
5

Pengalaman menyusui : Ya/Tidak Berapa lama :

Riwayat Kehamilan Saat Ini :

1. Berapa Kali Periksa Hamil :…………………………………………………………………
2. Masalah Kehamilan : ………………………………………………………………..

Riwayat Persalinan :
1. Jenis persalinan : spontan (letkep/letsu) /Tindakan (EF, EV)
SC a/i …………………………….. Tgl/Jam ………………………………….
2. Jenis Kelamin Bayi : L/P, BB/PB : …….gram/………cm, A/S………..
3. Perdarahan : …………………cc
4. Masalah Dalam Persalinan : …………………………………………

Riwayat Ginekologi :
1. Masalah Ginekologi : …………………………………………………………….
2. Riwayat KB : …………………………………………………………….

DATA UMUM KESEHATAN SAAT INI

Status Obstetrik : NH…….P……A…….Bayi Rawat Gabung : Ya/Tidak,

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Jika tidak alasan…………………………………………………………………………..
Keadaan Umum : ……………………………..Kesadaran………………………...
BB/TD : ……………Kg/………………cm

Tanda Vital :
Tekanan darah : ………..…mmHg, Nadi : ….…x/menit, Suhu : ……OC
Pernapasan : …………….x/menit

Kepala Leher :
Kepala: ………………………
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Mata : ………………………
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Hidung: ………………………
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Mulut: ………………………
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Telinga: ………………………
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Leher: ………………………
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MasalahKhusus: ………………………………………………………………........................................

Dada :
Jantung: ………………………
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Paru: ………………………
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Payudara: ………………………
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.................................................................................................................................................
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Puting susu : ………………………......................................................................................
Pengeluaran ASI : ………………………...............................................................................
Masalah Khusus ……………………….................................................................................

Abdomen :
Involusi Uterus : Fundus uterus : ………….Kontraksi : ………….Posisi : ………….
Kandung kemih : ........................................................................................................
Diastasis Rektus Abdominis ……………X………………cm
Fungsi Pencernaan : ………………………...........................................................................
Masalah Khusus ……………………….................................................................................

Perineum dan Genital :

Vagina : Integritas kulit………edema………memar………hematom……..
Perineum : Utuh / Episiotomi / Ruptur

Tanda REEDA :
R : Kemerahan (Ya/Tidak)
E : Bengkak (ya/Tidak)
E : Echimosis (Ya/Tidak)
D : Discharge Serum/pus/darah/Tidak ada
A : Approximate (Baik/Tidak)
Kebersihan vagina : …………………………………………........................................................
Lokia :.................. Jumlah : ....... cc; Jenis/warna :........../...........;
Konsistensi : ............... ; Bau : ..............................................
Hemorrhoid: derajat……………………..lokasi……………………………...................................
Berapa lama……………………. nyeri : (Ya/Tidak)
Masalah Khusus : ……………………………………………………………………

Ekstremitas :
Ekstremitas Atas : edema (Ya/Tidak)
Ekstremitas Bawah : edema (Ya/Tidak), lokasi………………………………………
Varises (Ya/Tidak), lokasi………………………………………………………………….
Tanda Homan :+/-
Masalah Khusus : …………………………………………………………………………..

Eliminasi :
Urine : Kebiasaan BAK…………………………………………………………………………………
………
BAK saat ini…………………………… nyeri : Ya/Tidak
BAB : Kebiasaan BAB……………………………………………………......................
BAB saat ini………………………….. konstipasi : Ya/Tidak
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 Masalah Khusus : …………………………………………………………….............

Istirahat dan Kenyamanan :

Pola tidur : Kebiasaan tidur, lama…….jam, frekuensi……………….....................
Pola tidur saat ini…………………………………………….................................................
Keluhan ketidaknyamanan : Ya/Tidak, lokasi……………………………................................
Sifat……………………….. intensitas……………………............................................................

Mobilisasi dan Latihan.

Tingkat mobilisasi : …………………………………………………………........................................
Latihan/senam : …………………………………………… Masalah Khusus : ………………………….

Nutrisi dan Cairan.

Asupan Nutrisi : …………................. nafsu makan : baik/kurang/tidak ada
Asupan Cairan : …………………………………. cukup/kurang
Masalah Khusus : …………………………………………………………….........................................

Keadaan Mental
Adaptasi psikologis : …………………………………………………………...........................
Penerimaan terhadap bayi : …………………………………………………..................................
Masalah Khusus : …………………………………………………………….......................
Kemampuan Menyusui...............................................................................................
Obat-obatan ...............................................................................................................

Hasil Pemeriksaan Penunjang :

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RANGKUMAN HASIL PENGKAJIAN

Masalah :
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Perencanaan Pulang :
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 Analisa Data
Data Etiologi Masalah
 Analisa Data
Data Etiologi Masalah

1
 Analisa Data
Data Etiologi Masalah

2
Diagnosa Prioritas Keperawatan:
1.

2.

3.

Nurse Care Planning

Diagnosa NOC NIC

3
 Nurse Care Planning
Diagnosa NOC NIC

4
 Nurse Care Planning
Diagnosa NOC NIC

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 Implementasi dan Evaluasi
Hari/Tgl/Waktu DX Implementasi Evaluasi Paraf

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 Implementasi dan Evaluasi
Hari/Tgl/Waktu DX Implementasi Evaluasi Paraf

7
 Implementasi dan Evaluasi
Hari/Tgl/Waktu DX Implementasi Evaluasi Paraf

8
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