ASUHAN KEPERAWATAN ANTENATAL PADA NY M G1P0A0 HAMIL 28 MINGGU DENGAN

APLIKASI MODEL KONSEP SISTER CALISTA ROY

DI RSUD CEMPAKA PUTIH

Nama mahasiswa : Masliha Tanggal pengkajian : ..........................

NPM : 2018980064 Jam Pengkajian : ..........................

PENGKAJIAN
I. Identitas
Identitas Ibu Identitas Suami
Nama (Inisial) : ____________ Nama (Inisial) : ____________
Umur : ____________ Umur : ____________
Agama : ____________ Agama : ____________
Suku Bangsa : ____________ Suku Bangsa : ____________
Status Perkawinan : ____________ Status Perkawinan : ____________
Pekerjaan : ____________ Pekerjaan : ____________
Pendidikan terakhir : ____________ Pendidikan terakhir : ____________
Alamat rumah : _______________________________________________________________________________

2. Riwayat Keperawatan
a. Keluhan Utama
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b. Riwayat Kehamilan Sekarang

Diagnosa Kehamilan : G___P___ A___
HPHT : ______________
Taksiran Partus : ______________
Usia Kehamilan : ______________

c. Riwayat Obstetri
1) Kehamilan, persalinan, dan nifas yang lalu

Tahun Tempat Usia Jenis Anak

No Penolong Penyulit Nifas Laktasi
partus Partus Kehamilan Persalinan JK BB TB

2) Riwayat Mestruasi
Menarche : ___________________________
 Siklus : ___________________________
Lama : ___________________________
Jumlah : ___________________________
Disminorea : ___________________________

d. Riwayat Penyakit Yang lalu

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e. Riwayat Penyakit Keluarga
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f. Riwayat Alergi
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g. Riwayat Pemakaian Alat Kontrasepsi
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3. Pemeriksaan Fisik
a. Keadaan Umum : ____________________
b. Kesadaran : ____________________
c. Tanda-tanda vital
Tekanan Darah : _____ mmHg Pernapasan : ______ x/menit
Nadi : _____ x/menit Suhu : _____0C
d. Head to toe
1) Kepala dan Rambut
Rontok : _______________________________________________________________________
Warna rambut : _______________________________________________________________________
Distribusi : _______________________________________________________________________
Kulit kepala : _______________________________________________________________________
Nyeri tekan : _______________________________________________________________________

2) Wajah
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3) Mata
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4) Hidung
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5) Mulut
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6) Telinga
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7) Leher
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8) Axilla
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9) Dada/Thorax
a) Sistem Pernapasan
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b) Sistem Kardiovaskuler
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c) Payudara
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10)Abdomen
a) Inspeksi
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b) Palpasi
Leopold I : _____________________________________________________________________
Leopold II : _____________________________________________________________________
Leopold III : _____________________________________________________________________
Leopold IV : _____________________________________________________________________

c) Auskultasi (DJJ)
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 11) Genetalia dan anus
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12) Ekstremitas bawah

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APLIKASI TEORI ADAPTASI ROY

1. Pengkajian tahap 1 :
a. Physiological mode (fungsi fisiologis)
1) Oksigenasi :
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2) Nutrisi
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3) Eliminasi :

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4) Aktivitas dan istirahat

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5) Proteksi

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6) Sense
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 7) Cairan dan elektrolit
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8) Fungsi neurologi :
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9) Fungsi endokrin :
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b. Self concept mode (Konsep diri)

1) Phsical self
Persepsi klien mengenai perubahan diri saat hamil (gambaran diri) :
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2). Personal self
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c. Role Funtion Mode (fungsi peran)

Bagaimana peran ibu saat ini :
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d. Interdependensi Mode
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2. Pengkajian tahap 2
a. Stimulus fokal
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b. Stimulus kontekstual

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c. Stimulus residual

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