FORMAT PENGKAJIAN DATA PADA IBU INPARTU

Nama siswa : Tanggal :

Nim : No.register :
Ruangan/RS : Diagnose medis :

BIODATA

A. identitas istri/ibu

Nama :
Umur :
Suku/bangsa :
Agama :
Pendidikan terakhir :
Pekerjaan :
Penghasilan/bulan :
Status perkawinan :
Perkawinan ke :
Lamanya :
Tanggal kunjungan :
Alamat :

B. Identitas suami
Nama :
Umur :
Suku/bangsa :
Agama :
Pendidikan terakhir :
Pekerjaan :
Penghasilan/bulan :
Status perkawinan :
Persalinan ke :
Lamanya :
Alamat :
A. DATA BIOLOGIS/FISIOLOGIS
a. Keluhan utama
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

b. Riwayat keluhan utama

…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………

c. Riwayat kehamilan yang sekarang

…………………………………………………………………………………
…………………………………………………………………………………
1. G : …………………………………………………………………………
P : …………………………………………………………………………
A : …………………………………………………………………………
2. HPHT: ……………………………………………………………………
Tafsiran persalinan……………………………………………………
3. pergerakan anak yang yang di rasakan ibu :
…………………………………………………………………………………
4. kunjungan yang ke
…………………………………………………………………………………
5. imunisasi TT
…………………………………………………………………………………
 d. Riwayat kehamilan dan persalinan serta nifas yang lalu :

No Kehamilan Persalinan Anak Riwayat

nifas
umu Keadaan Thn Tempat Penolong jeni L/P Lama Keadaan
r s menyusui sekarang

e. Pola reproduksi
Menarche Umur :
Siklus Haid :
Lamanya Haid :
Sifat Darah :
Dysmenorrhoe :

f. Riwayat Kesehatan
Riwayat apenyakit yang pernah dialami/terutama yang berpengaruh terhadap
kehamilan:
…………………………………………………………………………………
…………………………………………………………………………………
Riwayat operasi yang pernah dialami :
…………………………………………………………………………………
…………………………………………………………………………………
Riwayat keluagaPenyakit :
…………………………………………………………………………………
…………………………………………………………………………………
Riwayat Kehamilan kembar
……………………………………………………………………………..
g. Pola Kegiatan Sehari-hari:
1. Nutrisi
Jenis makanan………………………………………………………………
Frekwensi makanan/hari……………………………………………………
Nafsu makan………………………………………………………………..
Makanan pantang…………………………………………………………..
Banyaknya minum/hari…………………………………………………….
2. Eliminasi
Buang air besar (BAB)
Frekwensi/hari : …………………………………………………………..
warna : …………………………………………………………..
Konsistensi : …………………………………………………………..
Buang Air Kecil (BAK)
Frekwensi/hari : …………………………………………………………..
warna : …………………………………………………………..
jumlah : …………………………………………………………..
3. Istrahat dan Tidur
Tidur malam : jam……………s/d………………
Tidur Siang : jam……………s/d………………
4. Kebersihan Diri
Penampilan : …………………………………………………………..
Mandi/Hari : …………………………………………………………..
Sikat gigi/hari : …………………………………………………………..
Cuci Rambut/minggu: …………………………………………………….
Ganti pakaian dalam dan luar sehari: ……………………………………..
ganti pakaian dalam dan luar sehari : ……………………………………..
Rekreasi atau olah raga atau hobby : ……………………………………..
h. Ketergantungan:
………………………………………………………………...........................
i. Hubungan seksual,keluhan
………………………………………………………………...........................
j. Riwayat keluarga berencana
mengerti tentang KB : ………………………………………..........................
setuju tentang KB : ……………………………………….........................
 pernah menjadi akseptor : ………………………………………....................
drop out KB, alasannya : ……………………………………….....................

B. Pemeriksaan Fisik
Tanda vital
Tekanan darah :......................................................nadi :......................................
Pernapasan :..................................................... suhu :.....................................
berat badan :.................................................. tinggi badan :.........................
cara berjalan :.....................................................................................................
kesadaran umum:.......................................................................................................

C. Inspeksi
1. Kepala rambut :….....................................................................................
Muka pucat :.........................................................................................
kloasma gravidarum :.........................................................................................
sianosis :.........................................................................................
Oedema :
kelopak mata :.........................................................................................
sklera mata :.........................................................................................
konjugtiva :.........................................................................................

2. Mulut dan gigi

berbau :.........................................................................................
jumlah gigi :.........................................................................................
Caries :.........................................................................................
Stomatitis :.........................................................................................

3. Leher
Pembesaran kelenjar :.......................................................................................

4. Buah dada bentuknya :.................................................................................

keadaan pting susu :....................................................................................
pengeluaran kolostrum :..........................................................................
5. Perut
Bentuknya :..................................linea/striae:.........................................
Bekas luka operasi :..............................................................................................
6. Vulva
Oedema :..............................................tanda chadwick .......................
Pengeluaran dari vagina :...............................................................................................
Kebersihan .....................................................................................................................
Prolaps ......................................................................................................................
7. Tungkai :
Varises .......................................................................................................................
Oedema .......................................................................................................................
8. Pemeriksaan panggul luar dan perut
lingkar panggul ..................................................................................................
lingkar perut ..................................................................................................
distansia spinarum ......................................................................................
distansia cristarum ......................................................................................
boudeloque ......................................................................................
Palpasi menurut leopold
TFU : .....................................................................................
Panggung janin :.......................................................................................
Bagian terdepan :........................................................................................
Turunnya bagian terdepan :......................................................................................
Auskultasi :.....................................................................................................
Bunyi jantung :....................................................................................................
Frekuensi :....................................................................................................
Lokasi yang paling jelas :........................................................................................
Gerak janin :....................................................................................................
Bising rahim :....................................................................................................
Bunyi aorta :....................................................................................................
Bunyi jantung ibu:....................................................................................................
Bunyi paru ibu :....................................................................................................
Perkusi :
Refleks petella : kanan :.......................................................kiri: ..........................
9. Pemeriksaan laboratorium
a. Darah
Hb...................................................................................................................
VDRL..............................................................................................................
GOLONGAN DARAH ..................................................................................
b. URINE
Albumin ............................................................................................
Reduksi ............................................................................................
Plano test ............................................................................................
c. Pemeriksaan rontgen....... ................................................................................

D. RIWAYAT PERSALINAN SEKARANG DENGAN MENGUNAKAN

PATOGRAF

a. Kala I
Lamanya :..............................jam:.......................................menit
Pelepasan tanggal :..............................jam................................................
Tanda vital
Tekanan darah :.............................. nadi :...................................
Pernapasan :..............................suhu :..........................
Palpasi menurut leopold
TFU :.........................................................................
Punggung janini :.........................................................................
Bagian yang terdepan :......................................................................
Turunnya bagian terendah :...............................................................
His (kontraksi uteri)
Tanggal :.................................jam :...................................
Frekuensi :................................lamanya :............................
Intensitas/kekuatanya :.......................................................................
Vaginal touche
Di lakukan oleh :...........................................................................
Idikasi :...........................................................................
Tanggal :..........................................................................
Pembukaan :...........................................................................
Serviks :...........................................................................
 Ketuban :..................................................................................
Bagian paling bawah :.................................................................................
Presentasio :..................................................................................
Turunnya hodge :..................................................................................
Kesan panggul :..................................................................................
Rektum :...................................................................................
Pelepasan :..................................................................................

b. Kala II
1. lamanya :.................................jam :..............................menit :................
2. His intersitasnya
.......................................................................................................
3. Denyut jantung janin : frekuensi :........................
jumlahnya ................................
Bagian depan :................................presentasio ...........................
Turunnya :................................kesan panggul .........................
Pelepasan lendir........................................................................................
Ketuban pecah :................................oleh ..........................................
Warnanya :.....................baunya .................jumlahnya..............
Keadaan his :...............................keadaan perineum ...................
Ibu mulai mengedan :..............................caranya mengedan .................
Bayi lahir tanggal :................................jamnya ..................................
Jenis persalinan ..................................................................................
Perdarahan ............................................................................…cc
4. Keadaan bayi
Berat badan lahir :...........................................panjang badan....................
Cacat bawaan : ...........................................................................................
Apgar skor :1 menit setelah lahir :.............................................................
5 menit setelah lahir :...............................................................
Caput suksadenum :...................................................................................
Cephal hematon :......................................................................................
Setelah 5 menit apakah ada mekoneum :..................................................
 c. Kala III
lamanya :...........................................menit
TFU setelah bayi lahir :......................................................................
Katerisasi urine :..................................................................cc
Kontraksi uterus :…….....................................................................
Lahirnya plasenta : tanggal :....................................jam ......................
Pemeriksaan placenta :
Kotiledon :.....................................................................
Beratnya :.....................................................................
Selaput omnion :......................................................................

Tali pusat
Panjang :.................................................................cm
Keadaan :.....................................................................

Tanda vital
Tekanan darah :..................................................................
Pernapasan :..................................................................
Nadi :..................................................................
Suhu :..................................................................
Perdarahan :..................................................................

E. DATA PSIKOLOGIS

Pola interaksi ................................................................................................

Reaksi dan persepsi terhadap kehamilan .....................................................

Di rencanakan ............................................................................

Apakah klien cemas dengan persalinannya ..................................................

Jenis kelamin yang di harapkan ..................................................................

Bantuan pelayanan yang di harapkan ...........................................................

Kebutuhan kesehatan yang di harapkan ......................................................

Perawatan payudara agar asi cukup untuk kebutuhan bayi

 Bimbingan tentang perawatan bayi ...............................................................

Pelayanan yang telah di berikan ....................................................................

F. DATA SOSIAL

1. hubungan dengan keluarga , tentang dan lingkungan

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

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

2. siapa yang paling penting

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

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

3. tentang biaya kesehatannya

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

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

G. DATA SPIRITUAL
1. Bagaimana melaksanakan ibadah selama hamil
.......................................................................................................................
.......................................................................................................................
2. Bagaimanakepercyaan klien terhadap agama yang di anut
.......................................................................................................................
.......................................................................................................................

Palu,...........................

Mengetahui Yang Mengkaji

CI lahan praktek

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