Nama kelompok 4:

1. Dwy Meisaro

2. Evita Cahya N

3. Fitri Ayu A

4. Icha Kurnia T

5. Lailiyul A

6. Nurul Ida M

7. Rizky purnama A

8. Rizka Aliyah J

9. Safira Nurus S
 FORMAT PENGKAJIAN ASKEP IBU HAMIL

PENGKAJIAN

I. IDENTITAS

Nama ibu : Nama suami

:
Umur : Umur :
Pendidikan : Pendidikan. :
Agama : Agama :
Pekerjaan : Pekerjaan :
Status perkawinan :
Alamat :

Tanggal pengkajian :

Diagnosa medis :

2. DATA SUBJEKTIF

a. keluhan utama
.....................................................................................................................................................
.........................................................................................................................

b. riwayat Kesehatan Sekarang

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

c. Riwayat Kehamilan Sekarang

ANC(Ante Natal Care) :.........................teratur/tidak.................................................

Diperiksa : ..............................................................................................

Imunisasi :.............................................................................................

Usia kehamilan : .............................................................................................

d. Riwayat Menstruasi

Menarche ....................siklus......................lamanya..........teratur/tidak...........

Jumlah :......................Warna:..................dismenorhe:...................................
 HPHT :......................taksiran persalinan persalinan..............

e. Riwayat obsteri

G.............................P.................................A.........................................................

ANAK JENKEL UMUR RIWAYAT PERSALINAN

KE

LANIR USIA PENOLONG PENYULIT BBL KET

HAMIL

f. Riwayat Kesehatan / Penyakit Yang lalu :

penyakit
alergi
merokok dan obat-obatan
g. Riwayat penyakit Keluarga

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

h. Keadaan Psikososial

Perubahan kehamilan terhadap kehidupan sehari-hari.

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

Harapan yang didinginkan selama kehamilan

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

Ibu tinggal serumah dengan siapa

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

Yang menemani ibu ke klinik

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

Rencana melahirkan
...........................................................................................................................

Rencana menyusui
...........................................................................................................................
 i. Seksual

dampak kehamilan terhadap perubahan pola

seksual ..........................................................................................................................................

j. riwayat keluarga Berencana

 Jenis kontrasepsi yang pernah digunakan

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

 Masalah-masalah yang dailami selama kehamilan

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

 Jumlah anak yang direncanakan

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

k. pola kehidupan sehari-hari

 Pola makan
 Diet kebiasaan (jenis)
............................................................................................................................

 Perubahan dalam pola makan

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

 Pandangan selama kehamilan terhadap makanan

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

 Masalah mengunyah/menelan
............................................................................................................................

 Kenyamanan, aktivitas dan istirahat

 Kenyamanan selama kehamilan dan cara mengatasinya
............................................................................................................................

 Aktivitas/hobi kebiasaan
............................................................................................................................

 Aktivitas kesenangan
............................................................................................................................
Pembatasan selama kehamilan kondisi

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

 Perubahan istirahat, tidur,dan cara mengatasinya

........................................................................................................................... Jumlah
jam istirahat/ tidur perhari
 ............................................................................................................................ Pola
eleminasi

Buang Air Besar

 Dampak kehamilan terhadap pola eleminasi

 Frekuensi BAB :...............x/ hari
 Nyeri/ rasa panas saat BAB
 Perdarahan Hemoroid
Konstipasi Diare

Buang Air Kecil

 Frekuensi BAK :...............x/hari

 Kesulitan Berkemih Riwayat Penyakit Ginjal
Dorongan Penggunaan diuretik

 Personal higine
 Frekuansi mandi :...................X/hari
 Frekuensi gosok gigi :...................x/hari
 Perawatan Payudara :......................
 Vulva Higine :......................

3. PEMERIKSAAN FISIK

a. secara umum

Tanda- tanda vital

 Tekanan darah :......................................mm/Hg
 Suhu :......................................C
 Nadi :......................................x/ menit
 Pernapasan :......................................x/ menit
Berat badan sekarang :......................................Kg
Berat Badan sebelum lahir :..........................Kg
LILA :......................................Cm
b. Secara head To Toe

Kepala
 Rambut :...........................
 Muka :...........................
 Mata/ konjungtiva :...........................
 Hidung :...........................
 Mulut :...........................
Leher
 Inspeksi : Gondok :..........................................................
 Palpasi : Masa :..........................................................
 Auskultasi : Bruit Aorta :..........................................................
Dada
  Payudara membersar :.......................
 Puting susu :.......................
 Kebersihan :.......................
 Simetris :.......................
Abdomen
 Inspeksi
 Straiae Gravidarum :....................................
 Hiperpigmentasi :....................................
 Auskultasi
 DJJ :.....................................
 Bising usus :.....................................
 Palpasi
 Leopold I :.....................................
 Leopold II :.....................................
 Leopold III :.....................................
 Leopold IV :.....................................
 Perkusi :.....................................

Ekstremitas
 Kekuatan otot :.....................................
 Reflek Patela :.....................................
 Reflek Babinski :.....................................
 Edema :.....................................
 Chubb :.....................................
c. pemeriksaan laboratorium

 HB :...........................Gol. Darah :...............................................Rh+/-

 Urine :..........................................................................................................
 USG :..........................................................................................................
d. data penunjang therapy

........................................................................................................................................................
........................................................................................................................................................
..............................................................................................................
ANALISA DATA

DATA PENYEBAB MASALAH

DO

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

DS

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

RENCANA INTERVENSI

KRITERIA
NO DIAGNOSA TUJUAN INTERVENSI RASIONALISASI
HASIL

IMPLEMANTASI DAN RASIONALISASI

NO. DIAGNOSA HARI/TANGGAL TINDAKAN EVALUASI