FORMAT PENGKAJIAN DENGAN

13 DOMAIN NANDA-I

A. DATA UMUM
1. Nama :
2. Umur :
3. Alamat :
4. Pekerjaan :
5. Agama :
6. Tanggal masuk RS/RB:
7. Nomor RM :

B. DATA KESEHATAN UMUM

1. Masalah kesehatan khusus :
2. Konsumsi obat/jamu :
3. Riwayat alergi :
a. Obat-obatan :
b. Makanan :
c. Bahan kimia tertentu :
d. Cuaca :
e. Lain-lain :
4. Diet khusus :
5. Riwayat penyakit :
6. Menggunakan alat bantu
a. Gigi tiruan :
b. Kacamata :
c. Lensa kontak :
d. Alat dengar :
e. Lain-lain :

C. PENGKAJIAN 13 DOMAIN NANDA

1. PROMOSI KESEHATAN (Meliputi kesadaran kesehatan dan manajemen kesehatan):
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2. NUTRISI (Meliputi perbandingan antara intake sebelum dan selama kehamilan):
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3. ELIMINASI (Meliputi frekuensi BAK/BAB sebelum dan sesudah selama perawatan,
jelaskan karakteristik BAB/BAK tersebut, ada mual muntah tidak):
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4. AKTIVITAS DAN ISTIRAHAT (Meliputi jam tidur sebelum dan sesudah selama
perawatan, adakah gangguan tidur):
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5. PERSEPSI DAN KOGNISI (Meliputi cara pandang klien tentang proses persalinan dan
bayi yang akan dilahirkannya, apakah klien memiliki pemahaman yang cukup terkait
proses persalinan):
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6. PERSEPSI DIRI (Meliputi apakah klien merasa cemas/takut tentang proses persalinan
yang akan dilalui, apakah klien merasa senang dengan kehamilan sekarang):
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7. HUBUNGAN PERAN (Meliputi hubungan klien dengan suami/anggota keluarga dan
orang sekitarnya):
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8. SEKSUALITAS (Meliputi karakteristik kehamilan klien, apakah klien akan
menggunakan kontrasepsi setelah persalinan, apakah klien pernah mengalami
masalah seksual sebelum hamil):
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9. KOPING/ TOLERANSI STRES (Meliputi bagaimana cara klien mengatasi stressor
dalam proses kehamilan sekarang, jika bayi dalam kandungan terjadi sesuatu hal
yang tidak diinginkan apa yang akan dilakukan):
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10. PRINSIP HIDUP (Meliputi apakah klien tetap menjalankan ibadah selama proses
kehamilan, apakah klien mengikuti kegiatan keagamaan sebelum masuk perawatan,
apa prinsip hidup yang dimiliki):
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11. KEAMANAN/PERLINDUNGAN (Meliputi apakah klien menggunakan alat bantu jalan,
apakah pengaman disamping tempat tidur berfungsi dengan baik, apakah tersedia
selimut untuk mengatasi cuaca dingin):
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12. KENYAMANAN (Meliputi apakah klien merasa nyaman dengan proses kehamilan
sekarang, bagaimana penampilan psikologis klien):
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13. PERTUMBUHAN/PERKEMBANGAN (Meliputi berapakah kenaikan BB klien selama
kehamilan):
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