FORMAT PENGKAJIAN ANTENATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
.............................................................................................................................................

.………………………………………………………………………………………..…

2. Keluhan utama saat ini : ..................................................................……..................

.............................................................................................................................................
.…………………………………………………………………………………….……
3. Riwayat Kehamilan saat ini

4. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak (
)
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :
b. Riwayat kehamilan, persalinan, nifas :

Ana Kehami
Persalinan Komplikasi nifas Anak
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB pj
o long ksi han
u a ulit ulit si
n m
il
a
n

Genogram

2. RIWAYAT KELUARGA BERENCANA :

 Melaksanakan KB : ( ) ya ( ) tidak
 Bila ya jenis kontrasepsi apa yang
digunakan : ......................................................
 Sejak kapan menggunakan
kontrasepsi : ................................................................
 Masalah yang
terjadi : ............................................................................................
3. RIWAYAT KESEHATAN :
 Penyakit yang pernah dialami
ibu : ........................................................................
 Pengobatan yang
didapat : ......................................................................................
 Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

4. RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................
…………….......
- Bahaya :
…………......................................................................................................................
- Lainnya sebutkan : .................................................................................
…………………….....................

5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

6. KEBUTUHAN DASAR KHUSUS :

a. Pola Nutrisi
 Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu,
alasan ..........................................
 Jenis makanan rumah : ................................................................................….
 Makanan yang tidak disukai/ alergi/
pantangan : .............................................

b. Pola eliminasi :
 BAK
- Frekwensi : ....................kali
- Warna : .......................
……………………………………………….
- Keluhan saat BAK : .................................................
 ………......................

 BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : .............
……………………………………………….........
- Keluhan : ..............................................................................
………....
c. Pola personal hygiene
 Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
 Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
 Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
 Lama tidur : ............................jam/hari
 Kebiasaan sebelum tidur : ................................................................................
 Keluhan : ..........................................................................................................

e. Pola aktifitas dan latihan

 Kegiatan dalam pekerjaan : ..............................................................................
 Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
 Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
 Kegiatan waktu
luang : .....................................................................................
 Keluhan dalam beraktifitas : ............................................................................

f. Pola kebiasaan yang mempengaruhi kesehatan

 Merokok : .............................................................................................
.
 Minuman keras
: ..............................................................................................
 Ketergantungan obat
: ..............................................................................................

7. PEMERIKSAAN FISIK
 Keadaan umum : ......................................Kesadaran : .........................
 Tekanan darah : ......................................Nadi :
 .............x/menit
 Respirasi : ......................................Suhu : .......…........C
 Berat badan : ......................kg Tinggi badan :
................cm

Kepala, mata kuping, hidung dan tenggorokan :

Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak
mata : .....................................................................................................
 Gerakan
mata : ....................................................................................................
 Konjungtiva : ..............................................................................................
.......
 Sklera : .............................................................................................
.......
 Pupil : ...............................................................................................
......
 Akomodasi : ...............................................................................................
......
 Lainnya
sebutkan : .................................................................................................

Hidung :
 Reaksi
alergi : .....................................................................................................
 Sinus : .............................................................................................
.......
 Lainnya
sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi
geligi : .....................................................................................................
 Kesulitan
menelan : ................................................................................................
 Lainnya
sebutkan : .................................................................................................

Dada dan Axilla

 Mammae : membesar ( ) ya ( ) tidak
 Areolla
mammae : ..................................................................................................
 Papila
mammae : ....................................................................................................
 Colostrum : ...............................................................................................
......

Pernafasan
 Jalan
nafas : .....................................................................................................
 Suara
nafas . : ....................................................................................................
 Menggunakan otot-otot bantu
pernafasan : ............................................................
 Lainnya
sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : .........................................................................................
......
 Kelainan bunyi
jantung : ........................................................................................
 Sakit
dada : ...............................................................................................
 Timbul .: .........................................................................................
......
 Lainnya
sebutkan : ..............................................................................................

Abdomen
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak
 Leopold I :
 Leopold II :
 Leopold III:
 Leopold IV:
 Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :

Genitourinary
 Perineum : .........................................................................................
......
 Vesika
Urinasria : ...............................................................................................
 Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
 Vagina : varises: ya/ tidak
  Kebersihan :
 Keputihan :
 Jenis/warna :

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

8. Kesiapan dalam kehamilan dan persalinan:

a. Senam hamil
b. Rencana tempat melahirkan
c. Perlengkapan kebutuhan bayi dan ibu
d. Kesiapan mental ibu dan keluarga
e. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan

9. Data Penunjang
1) Laboratorium
: .................................................................................................
2) USG
: .................................................................................................
3) Rontgen : .................................................................................
................
4) Terapi yang
didapat: ..........................................................................................................................
........................................................................................................................................
...........................................................................................................

10. Data Tambahan

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................
Surabaya, ...................
.....................
Pemeriksa

(..................................................)
 ANALISA DATA

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................

No Data Penyebab Masalah

1. Ds.

Do.

2. Ds

Do.

3. Ds.

Do.

4. Ds.

Do.

5. Ds.

Do.

dst
PRIORITAS MASALAH
NAMA KLIEN : Ruangan / kamar : ......../.........
UMUR : No. Register :...............................

TANGGAL Nama
No Diagnosa keperawatan
ditemukan Teratasi perawat

RENCANA KEPERAWATAN
Nama Klien :...................... No Rekam Medis :....................... Hari Rawat Ke :............

No Diagnosa keperawatan Tujuan Rencana Intervensi Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

NAMA KLIEN : Ruangan / kamar : ......../.........
UMUR : No. Register :...............................
No Tgl Tindakan TT Tgl Catatan Perkembangan TT
Dx Jam Perawat Jam Perawat
Dx 1 :
S.
O

A
P
Dx. 2 :
S.
O

A
P
Dx 3 :.......
S.
O

A
P
Dx 4 :.......
S.
O

A
P

dst