Format Pengkajian Pada Ibu Hamil

I. DATA SUBJEKTIF

A. IDENTITAS/BIODATA

Nama Ibu : Nama Suami :

Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat Rumah : Alamat rumah :
Telepon : Telepon :

B. ANAMNESA (DATA SUBJEKTIF)

Tanggal : Pukul :
1. Kunjungan ke : ............................................................................
2. Alasan kunjungan/ keluhan utama
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Riwayat psikososial
a. Kehamilan ini ( ) Direncanakan
( ) Tidak direncanakan
( ) Diterima
( ) Tidak diterima
b. Perasaan tentang kehamilan ini : ..........................................................
c. Emosional ibu pada saat pengkajian : ..........................................................
d. Jenis kelamin yang diharapkan : ..........................................................
e. Status perkawinan
Kawin I Umur : ...........................Umur suami : ...................
Lamanya : ...............Anak .....Orang Abortus........x
Kawin II Umur : ............................Umur suami : ..................
Lamanya : ...............Anak .....orang Abortus .......x

f. Susunan keluarga/ genogram :

g. Perilaku kesehatan
Meroko ( ) Ya ( ) Tidak
k
 Alkohol ( ) Ya ( ) Tidak
Narkob ( ) Ya ( ) Tidak
a
4. Riwayat obsetri
a. Riwayat haid
Umur menarche : .........Tahun Teratur/ tidak teratur
Siklus : ..........Hari Lamanya : ...........hari
Banyaknya : .......... kali / pembalutSifat darah:..............
Warna darah :.........................
b. Riwayat kehamilan
HPHT :...................................
TP :...................................
Keluhan-keluhan Trimester I : ..........................................................
Trimester II : .........................................................
Trimester III: .........................................................
Pergerakan anak pertama kali dirasakan : Hamil ...................Minggu

Bila pergerakan anak sudah terasa, pergerakan anak dalam 24 jam

( ) kurang dari 10 kali
( ) lebih dari 10 – 20 kali
( ) lebih dari 20 kali

Bila lebih dari 20 kali dalam 24 jam, dengan frekuensi

( ) kurang dari 15 detik
( ) lebih dari 15 detik
( ) ..............................

Bila ada pergerakan keluhan yang dirasakan : .............................................

5. Riwayat kehamilan, persalinan dan nifas yang lalu G P A
Hami Tgl/Bln/Th BBL JK Jenis Umur Penyulit Penolong Ket.
l Ke n persalina kehamila kehamilann
n n

6. Riwayat KB
…………………………………………………………………………………
…………………………………………………………………………………
……………………………………………………………………………........

7. Riwayat kesehatan
 Penyakit yang pernah diderita
Penyakit Klien Keluarga
Jantung
Tekanan darah tinggi
Hepar
Diabetes melitus
PHS
Campak
Malaria
TBC
Keturunan kembar : ................................. Dari pihak : ....................

8. Riwayat Kebiasaan
a. Pola makan
........................................................................................................................
........................................................................................................................
.......................................................................................................................
b. Pola eliminasi
........................................................................................................................
........................................................................................................................
........................................................................................................................
c. Personal hygiene
........................................................................................................................
........................................................................................................................
........................................................................................................................
d. Aktivitas sehari-hari
........................................................................................................................
........................................................................................................................
........................................................................................................................
e. Pola istirahat dan tidur
........................................................................................................................
........................................................................................................................
........................................................................................................................
f. Seksualitas
........................................................................................................................
........................................................................................................................
........................................................................................................................
9. Riwayat imunisasi
TT: ( ) dapat ( ) tidak dapat berapa kali : .......kali
Tanggal Pemberian TT :
I............II............. III............. IV............. V.............

II. DATA OBJEKTIF

C. PEMERIKSAAN FISIK
1. Kesadaran umum
..............................................................................................................................
..............................................................................................................................
2. Tanda-tanda Vital
Respirasi :.................x/menit Nadi :................x/menit
Tekanan darah:.................mmHg Suhu :................°C
3. BB sekarang : ...........kg
BB sebelum hamil : ...........kg
TB : ...........cm
LILA : ...........cm
4. Kepala dan rambut
Warna rambut : ........................................................................................
Distribusi : ........................................................................................
Kebersihan : ........................................................................................
Kekuatan : ........................................................................................
Keadaan kulit kepala : ........................................................................................
5. Muka
Oedema : ........................................................................................
Cloasmagravidarum : ........................................................................................
6. Mata
Conjungtiva : ........................................................................................
Sklera : .......................................................................................
Kemampuan penglihatan : ...................................................................................
7. Hidung
Pengeluaran : ........................................................................................
Kemampuan penciuman: .....................................................................................
8. Mulut
Gigi : ........................................................................................
Gusi : ........................................................................................
Keadaan mukosa bibir: ........................................................................................
9. Telinga
Letak telinga : ........................................................................................
Kemampuan pendengaran: ..................................................................................
Pengeluaran : .......................................................................................
10. Leher
Pembesaran kelenjar tiroid : ...........................................................................
Pembesaran vena jugularis : ...........................................................................
Pembesaran kelenjar getah bening : ................................................................
11. Dada
Simestris : ........................................................................................
Pergerakan dada : ........................................................................................
12. Mamae
Kesimetrisan : ........................................................................................
Hiperpigmentasi areola: ......................................................................................
Bentuk payudara : ........................................................................................
Keadaan putting susu : ........................................................................................
Cairan yang keluar : ........................................................................................
 13. Abdomen
Warna/ Hiperpigmentasi : ...................................................................................
Bekas luka : ........................................................................................
Linea : ........................................................................................
Striae : ........................................................................................
Leopold I : ................................................................TFU...........Cm
Leopold II : ........................................................................................
Leopold III : ........................................................................................
Leopold IV : ........................................................................................
Perlimaan : ........................................................................................
DJJ : .......................................................................................
TBBJ : ........................................................................................

14. Genitalia
Oedema : ........................................................................................
Varises : ........................................................................................
Pembesaran kelenjar : ........................................................................................
Pengeluaran cairan : ........................................................................................
Bekas episiotomi : ........................................................................................
Kemerahan : ........................................................................................
Nyeri : ........................................................................................
Chadwick : ........................................................................................
15. Anus : ........................................................................................
16. Ekstremitas
Tangan : kuku : ........................................................................................
Oedema :........................................................................................
Kaki : varises : ........................................................................................
Oedema : ........................................................................................
Refleks patella : ..................................................................................

17. Punggung
Lordosis : ........................................................................................
Kiposis : ........................................................................................
Skoliosis : ........................................................................................
Ketuk costovetebra : ........................................................................................
18. Ukuran panggul luar
Distantia spinarum : ........................................................................................
Distantia kristarum : ........................................................................................
Conjungata eksterna : ........................................................................................
Lingkar panggul : ........................................................................................
19. Ukuran panggul dalam: .......................................................................................

D. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal : ............................................
Darah : HB : ...................................
Golongan darah : ...................................
Rhesus : ...................................

Urine : Protein : ...................................

 Reduksi : ...................................
RDT Malaria : ............................................
Sifilis : ............................................
HIV AIDS : ............................................
HBs Ag : ............................................

2. Pemeriksaan penunjang lainnya

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