Pengkajian Asuhan Keperawatan Antenatal Care Pada Ny. ...

G..., P..., A... Dengan...... Di

PENGKAJIAN PRENATAL
Nama Mahasiswa: Tgl. Pengkajian :
Nim : Ruangan/RS :
Tanggal masuk Rumah Sakit :

DATA UMUM KLIEN

Nama Mahasiswa : Tanggal pengkajian :
NIM : Ruangan/RS :
No. Reg : Tanggal Masuk Rumah Sakit :
Diagnosa Medis :

I. Data umum klien

1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

Riwayat Kehamilan dan Persalinan yang lalu

Jenis Jenis Keadaan Bayi Masalah
No Tahun Penolong
Persalinan Kelamin waktu lahir Kehamilan
1.
2.
3.
4.
5.
Pengalaman menyusui ekslusif: 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 ......................................

TD BB/TB Letak/presentasi DJJ Usia Keluhan Data Lain

 janin Gestasi

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/mnt
Kepala Leher
Kepala :...............................................................................
Mata :...............................................................................
Hidung :...............................................................................
Mulut :...............................................................................
Telinga :...............................................................................
Leher :...............................................................................
Masalah Khusus :...............................................................................
Dada
Jantung :..............................................................................
Paru :..............................................................................
Payudara :..............................................................................
Puting susu :..............................................................................
Pengeluaran ASI :..............................................................................
Masalah Khusus :..............................................................................
Abdomen
Uterus
TFU :.................cm kontraksi : ya/tidak
Leopold I : Kepala/bokong/kosong
Leopol II : Kanan : punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/bokong/kepala
Leopold III : Kepala/bokong/kosong
Leopold IV : Bagian masuk PAP
Pigmentasi
Linea Nigra :
Striae :
Fungsi pencernaan :
Ada/tidak luka operasi:
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
Varises: ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises: ya/tidak
Refleks patela : +/- jika ada :
Masalah khusus :.............................................................................................................
Eliminasi
Urin : kebiasaan BAK......................................................................................................
Fekal : kebiasaan BAB......................................................................................................
Masalah khusus :.................................................................................................................
Mobilisasi dan Latihan
Tingkat Mobilisasi :......................................................................................................
Latihan/senam :......................................................................................................
Masalah Khusus :......................................................................................................
Nutrisi dan Cairan
Asupan nutrisi (frekuensi dan porsi makan jenis makanan)
.............................................................................................................................................
Nafsu Makan : baik/kurang/tidak ada
Asupan cairan :...................................................................................................................
Masalah khusus....................................................................................................................
Seksualitas
Frekuensi :............................................................................................................................
Posisi :.............................................................................................................................
Masalah khusus:...................................................................................................................
Dukungan suami/keluarga terhadap kehamilan:
......................................................................................................................................................
......................................................................................................................................................
Keadaan Mental
Adaptasi psikologis :..............................................................................................................
Penerimaan terhadap kehamilan :.........................................................................................
Masalah khusus:....................................................................................................................
Pola hidup yang meningkatkan resiko kehamilan :
......................................................................................................................................................
......................................................................................................................................................
Persiapan Persalinan
 Senam Hamil
 Rencana tempat melahirkan
 Kesiapan biaya persalinan
 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

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
........................................................................

Perencanaan Kunjungan Rumah :

Pengkajian Asuhan Keperawatan PostnatalCare Pada Ny. ...

 Dengan Persalinan...... Di............

PENGKAJIAN POST PARTUM

Nama Mahasiswa : Tanggal Pengkajian :
Nim : Ruangan/RS :
Tanggal Masuk Rumah Sakit :
DATA UMUM KLIEN
1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

Riwayat Kehamilan dan Persalinan Yang Lalu

No. Tahun Tipe Penolong Jenis Penyulit BB Keadaan Masalah
Persalinan Kelamin persalinan Lahir bayi kehamilan
waktu
lahir

Pengalaman menyusui ekslusif: ya/tidak berapa lama :

Riwayat Kehamilan saat ini

1. Berapa kali periksa kehamilan
2. Masalah kehamilan

Riwayat Persalinan
1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV, EF)
SC...........................tgl/jam :...................
2. Jenis kelamin bayi : L/P, BB/PB :......gram/..........cm
3. Pengeluaran darah per vaginam :..............................cc
4. Masalah dalam persalinan ............................................

Riwayat Ginekologi
1. Masalah ginekologi
2. Riwayat KB

DATA UMUM KESEHATAN SAAT INI

Keadaan umum:.................kesadaran :........................BB/TB.................Kg/cm
Tanda vital
Tekanan Darah :...........mmHg; Nadi:.........x/mnt, Suhu:...........oC, Pernapasan :.............x/mnt
Kapala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah khusus:........................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI:
Masalah khusus:........................................................
Abdomen
Involusi Uterus
Fundus Uteri :..................... kontraksi :....................... posisi:................................
Kandung kemih
Diastaksis 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 : Edema :ya/tidak
E : Ekimosis :ya/tidak
D : Dischargeserum/pus/darah/tidak ada
A : Approximate : baik/tidak
Kebersihan :............
Lokia :
Jumlah :................. Jenis/warna :..............Konsistensi :.............. Bau :.....................
Hemorrhoid :
Derajat : ......................... lokasi :............................
Berapa lama :....... nyeri : ya/tidak
Masalah khusus :....................................................

Ekstremitas
Ekstremitas atas
Edema : ya/tidak
 Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Tanda Homan : +/-
Masalah khusus :.................................................................................................
Eliminasi
Urin : kebiasaan BAK
BAK saat ini.........................nyeri/tidak
Fekal : kebiasaan BAB....................................
BAB saat ini ........................ konstipasi/tidak
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 yang dikonsumsi saat ini :

Hasil pemeriksaan penunjang :

RANGKUMAN HASIL PENGKAJIAN

Masalah :
......................................................................................................................................................
......................................................................................................................................................
Perencanaan Pulang :
......................................................................................................................................................
......................................................................................................................................................
Pengkajian Asuhan Keperawatan Gangguan Sistem Reproduksi Pada Ny....
Dengan......Di.................
PENGKAJIAN GANGGUAN SISTEM REPRODUKSI (GSR)

Nama Mahasiswa : Tanggal pengkajian :

NIM : Ruangan/RS :
No. Reg : Tanggal Masuk Rumah Sakit :
Diagnosa Medis :

I. Data umum klien

1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

II. Masalah utama

Keluhan utama : ..............................................................................................................
Mulai timbulnya : ............................................................................................................
Sifat keluhan : .................................................................................................................
Lokasi keluhan : ..............................................................................................................
Faktor pencetus : .............................................................................................................
Keluhan lain : ..................................................................................................................
Pengaruh keluhan terhadap aktivitas/fungsi tubuh :........................................................
Usaha klien untuk mengatasinya : ..................................................................................
III. Pengkajian Fisik
Seksualitas
Subyektif :
Usia menarche : .................... tahun
Siklus haid : ........................... hari
Durasi haid : ...........................hari
Dismenorea Polimenorea Oligomenorea

Menometroragie Amenorea
Rabas pervagina : warna :.............................................................
Jumlah : ..........................................................
Berapa lama : .................................................
Metode kontrasepsi terakhir : ........................................................
Status obstetri : P................ A :.................
Riwayat persalinan :
Aterm : ............................. prematur :.............................
Multiple : ....................................
Riwayat persalinan terakhir :
Tahun : ...................................... tempat : ...............................
Lama gestasi:............................. lama persalinan :..................
Jenis persalinan : ......................
Berat badan bayi :.....................
Komplikasi maternal/bayi : ........................................
Obyektif :
PAP smear terakhir (tgl dan hasil) : .........................................................................
Tes serologi (tgl dan hasil) : .....................................................................................
Makanan dan cairan
Subyektif :
Masukan oral 4 jam terakhir : ..................................................................................
Mual/muntah hilang nafsu makan masalah mengunyah
Pola makan :
Frekuensi : .............. x/hari
Konsumsi cairan :................/hari
Obyektif :
BB : ...................kg
TB :....................cm
Turgor kulit : ..............................................................................................................
Membran mukosa mulut : ..........................................................................................
Kebutuhan cairan : ..........................................................................................................
Pemeriksaan Hb. Ht (tgl dan hasil) :................................................................................
Eliminasi
Subyektif :
Frekuensi dafekasi : ........................................................................................................
Penggunaan laksatif : ......................................................................................................
Waktu defekasi terakhir : ................................................................................................
Frekuensi berkemih : .......................................................................................................
Karakter urine : ................................................................................................................
Nyeri/rasa terbakar/kesulitan berkemih :.........................................................................
Riwayat penyakit ginjal :..................................................................................................
Penyakit kandung kemih :................................................................................................
Penggunaan diuretik :.......................................................................................................
Obyektif :
Pemasangan kateter :........................................................................................................
Bising usus : ....................................................................................................................
Karakter urine : ................................................................................................................
Konsistensi feces : ...........................................................................................................
Warna feces : ...................................................................................................................
Hemorrhoid : ...................................................................................................................
Palpasi kandung kemih (teraba/tidak teraba) :.................................................................
Hygiene
Subyektif :
 Kebersihan rambut (frekuensi ) :......................................................................................
Kebersihan badan :...........................................................................................................
Kebersihan gigi/mulut : ...................................................................................................
Kebersihan kuku tangan dan kaki : .................................................................................
Obyektif :
Cara berpakaian : .....................................................................................................
Kondisi kulit kepala : ..............................................................................................
Sirkulasi
Subyektif :
Riwayat penyakit jantung : ..............................................................................................
Riwayat demam reumatik :...............................................................................................
Obyektif :
Tekanan darah : ...............................................................................................................
Nadi :.................................................................................................................
Distensi vena jugularis (ada/tidak ada) : .........................................................................
Bunyi jantung : ................................................................................................................
Frekuensi : .......................................................................................................................
Irama (teratur/tidak teratur) : ...........................................................................................
Kualitas (kuat/lemah/Rub/Murmur) ; .............................................................................
Ekstremitas :
Suhu (hangat/akral dingin) : ............................................................................................
CRT : ...............................................................................................................................
Varises (ada/tidak ada) : CRT : .......................................................................................
Nyeri/ketidaknyamanan
Subyektif :
Lokasi : ............................................................................................................................
Intensitas (skala 0 -10) : ..................................................................................................
Frekuensi : .......................................................................................................................
Durasi : ............................................................................................................................
Faktor pencetus : .............................................................................................................
Cara mengatasi : ..............................................................................................................
Faktor yang berhubungan : ..............................................................................................
Obyektif :
Wajah meringis
Melindungi area yang sakit
Fokus menyempit
Pernapasan
Subyektif :
Dispnea Batuk/sputum Riwayat Bronkitis
Asma Tuberkulosis Emfisema
Pneumonia berulang Perokok, lamanya : ............. tahun
Penggunaan alat bantu pernapasan (02) : ..............L/mnt
Obyektif :
Frekuensi : ......................x/mnt
 Irama :
Eupnoe Tachipnoe Bradipnoe
Apnoe Hiperventilasi Cheynestokes
Kusmaul Biots
Karakteristik Sputum :
Hasil Roentgen :

Interaksi sosial
Subyektif :
Status pernikahan :
Lama pernikahan :
Tinggal serumah dengan :
Obyektif :
Komunikasi verbal/nonverbal dengan orang terdekat :

Integritas Ego
Subyektif :
Perencanaan kehamilan : .................................................................................................
Perasaan klien/keluarga tentang penyakit : .....................................................................
Status hubungan : ............................................................................................................
Cara mengatasi stress : ....................................................................................................
Obyektif :
Status emosional (cemas, apatis, dll) :............................................................................
Respon fisiologis yang teramati : ....................................................................................
Agama : ...........................................................................................................................
Muncul perasaaan (tidak berdaya, putus asa, tidak mampu) :.........................................

Neurosensori
Subyektif :
Pusing (ada/tidak ada) :.............................................................................................
Kesemutan/kebas/kelembaban (lokasi) : ..................................................................

Keamanan :
Subyetif :
Alergi/sensitivitas : .......................................................................................................
Penyakit masa kanak-kanak : ........................................................................................
Riwayat imunisasi : .......................................................................................................
Infeksi virus terakhir : ...................................................................................................
Binatang peliharaan dirumah : ......................................................................................
Masalah obstetrik sebelumnya : ....................................................................................
Jarak waktu kehamilan terakhir : ..................................................................................
Riwayat kecelakaan : .....................................................................................................
Fraktur dislokasi : ..........................................................................................................
Pembesaran kelenjar : ....................................................................................................
Obyektif :
 Integritas kulit : ..............................................................................................................
Cara berjalan : ................................................................................................................

Penyuluhan/pembelajaran
Subyektif :
Bahasa dominan : ............................................................................................................
Pendidikan terakhir : .......................................................................................................
Pekerjaan suami :..............................................................................................................
Faktor penyakit dari keluarga : ........................................................................................
Sumber pendidikan tentang penyakit : ............................................................................
Pertimbangan rencana pulang
Tanggal informasi diambil : .................................................................................................
Pertimbangan rencana pulang : ............................................................................................
Tanggal perkiraan pulang : ...................................................................................................
Ketersediaan sumber kesehatan terdekat : ...........................................................................

Pemeriksaan diagnostik :

Terapi dan pengobatan :