KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN

PROGRAM PROFESI NERS
Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816

ASUHAN KEPERAWATAN KLIEN PADA MASA KEHAMILAN

TANGGAL PENGKAJIAN: NAMA MAHASISWA/I:

TANGGAL MASUK RS : NIM :

NO.REGISTER : TANDA TANGAN :

RUANGAN :

DIAGNOSA MEDIS :
 I. BIODATA

1. Nama :.........................................................................................
2. Umur :..............................................Pendidikan.........................
3. Suku Bangsa :.........................................................................................
4. Alamat :.........................................................................................
...............................................................................................................................................
5. Nama Suami :.........................................................................................
6. Agama :.........................................................................................
7. Pekerjaan :.........................................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama/Alasan MRS :.........................................................................................

2. Riwayat Kesehatan Sekarang :.........................................................................................

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

3. Penyakit terdahulu yang mempengaruhi kehamilan :...........................................................

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

4. ANC/Antenatal Care : I / II / III / IV

5. Riwayat Haid :.........................................................................................

a. Menarche :................................................................

b. Haid Terakhir/HPHT :....................................................Taksiran

partus.

c. Siklus Haid : Teratur / Tidak Teratur (28 hari, 30 hari, 35 hari)

d. Lama :.........................................................................................

e. Banyaknya :.........................................................................................

f. Masalah :.........................................................................................

Masalah Keperawatan :
6. Riwayat Kontrasepsi

a. Jenis Alat Kontrasepsi yang digunakan :.............................................................................

b. Kapan Menggunakan :.............................................................................

c. Masalah :.............................................................................

7. Riwayat kehamilan yang lalu

a. Gravid :.......................... Para :.......................... Abortus :............................

b. Jumlah anak yang hidup :.............................................................................

c. Siapa yang menolong persalinan :.......................................Dimana.........................

d. Komplikasi yang terjadi sewaktu kehamilan yang lalu :

1) Tidak Ada

2) Ada, Sebutkan
(..............................................................................................................)

e. Komplikasi yang terjadi waktu persalinan dan kehamilan

1) Sectio
casaria....................................................Penyebab................................................

2) Perdarahan.........................................................Jumlah .................................................
.

3) Kejang ............................................................................................................................
.

4) Persalinan
Lama...............................................................................................................

f. Masalah waktu nifas :

1) Perdarahan.................................................................................................................

2) Infeksi........................................................................................................................
 3) Anemia......................................................................................................................

g. Masalah pada bayi yang dilahirkan :

1) Apgar Score :.........................................................................................

2) Gangguan Pernafasan :.........................................................................................

3) Icterus :.........................................................................................

4) Lahir Mati :.........................................................................................

8. Riwayat Pengobatan/Rokok/Alkohol :

a. Obat yang digunakan :

b. Tujuan pengobatan :

c. Ketergantungan dengan rokok :

d. Penggunaan alkohol :

e. Jenis imunisasi selama hamil :..................................Kapan pemberian......................

9. Masalah yang dirasakan/keluhan :

a. Mual : YA / TIDAK Muntah : YA / TIDAK

b. Nyeri ulu hati :.............................................................................

c. Gangguan BAK :.............................................................................

d. Pendarahan :.............................................................................

e. Gangguan tidur dan istirahat :.............................................................................

f. Kram pada kaki/kejang :.............................................................................

g. Pusing/sakit kepala :.............................................................................

h. Kelelahan :.............................................................................

i. Obstipasi :.............................................................................

j. Sakit Pinggang :.............................................................................

Masalah Keperawatan :
10. Pola kegiatan sehari-hari

a. Istirahat dan Tidur

1) Malam hari ................Jam Siang hari....................Jam

2) Apakah ada gangguan................................... Jenis

gangguan..............................

b. Personal Hygiene

1) Berapa kali
mandi................................................................................................

2) Perawatan gigi...................................................Berapa kali sikat

gigi.................

c. Aktivitas

1) Apakah ada gangguan dalam

pergerakan/jalan....................................................

d. Makanan dan Minuman

1) Berapa kali makan sehari...........................................Nafsu

makan.....................

2) Pantangan............................................................................................................
.

3) Diet......................................................................................................................
.

e. Eliminasi

1) Masalah
BAB.......................................................................................................

2) Diare/Konstipasi..................................................................................................
.

3) Masalah
BAK.......................................................................................................

f. Seksual
 1) Apakah ada perubahan : YA................. TIDAK.......................................

2) Jenis perubahan yang

dialami:.............................................................................

Masalah Keperawatan :

III. PSIKOSOSIAL

1. Status emosi : Stabil................................ Labil.................................................

2. Status Perkawinan :......................................Usia waktu menikah..............................

3. Rencana dan persepsi terhadap kehamilan

a. Direncanakan : YA / TIDAK

b. Diharapkan : YA / TIDAK

c. Jenis anak yang diharapkan :................................................................

d. Orang yang paling penting bagi klien :.................................................................

e. Rencana tempat melahirkan :.................................................................

f. Rencana mengikuti senam hami :.................................................................

g. Rencana memberikan ASI : YA / TIDAK

Masalah Keperawatan :

IV. RIWAYAT KESEHATAN KELUARGA

:.................................................................

V. PEMERIKSAAN FISIK

1. Tanda-tanda vital

a. Tekanan Darah :..............................

 b. Nadi :..............................

c. Suhu :..............................

d. Respirasi :...............................

2. Berat badan............................ kg Tinggi badan...................................... cm

3. Kulit

a. Warna.................................................

b. Kekenyalan.........................................

c. Perlukaan............................................

d. Hyperpigmentasi.................................

4. Rambut

Warna:............................................Distribusi..................................................................

5. Kepala

a. Ukuran seimbang dengan badan (Ya/Tidak) :.....................................................

b. Pergerakaan sendi (Ya/Tidak) :.....................................................

6. Leher

a. Pembesaran kelenjar tiroid (Ya/Tidak) :.....................................................

b. Pembesaran Vena Jugularis (Ya/Tidak) :.....................................................

7. Mata

Konjungtiva :................................... Anemia :.................................

8. Hidung

Apakah ada kelainan :....................................

9. Gigi dan Mulut :.....................................

10. Bentuk Dada :.....................................

11. Buah Dada :

 a. Bentuk buah dada Kiri....................................... Kanan.............................................

b. Konsisionsi (keras/lembut) :.......................................................................................

c. Simetris dalam ukuran kiri/kanan (Ya/Tidak)............................................................

d. Pembesaran Kiri/Kanan (Ya/Tidak)...........................................................................

e. Hyperpigmentasi aerola dan putting (Ya/Tidak)........................................................

f. Putting susu menonjol (Ya/Tidak).............................................................................

g. Pembesaran pembuluh vena (Ya/Tidak)....................................................................

h. Kolostrum (ada/tidak)................................................................................................

12. Abdomen

a. Pembesaran Kiri/Kanan (Ya/Tidak)...........................................................................

b. Bentuk perut...............................................................................................................

c. Linea nigra..................................................................................................................

d. Striae albikan..............................................................................................................

e. Perlukaan....................................................................................................................

f. Jaringan Perut.............................................................................................................

g. Palpasi (Leopold).......................................................................................................

I :.............................................................................................................................

II :.............................................................................................................................

III :.............................................................................................................................

IV :.............................................................................................................................

h. Mc. Donald rule :.....................................cm

i. Auskultasi :

1) Frekuensi :...........................................

2) Regularity :...........................................

3) Lokalisasi :...........................................
 j. Pergerakan anak :...........................................

13. Panggul luar (untuk primi para)

a. Distansia spinarum (23 cm) :......................................cm

b. Distansia cristarum (26 cm) :......................................cm

c. Boudelequa (16 cm) :......................................cm

d. Ukuran Lingkar Pinggang (80 cm) :.....................................cm

14. Ekstremitas

a. Ukuran kaki simetris :............................................

b. Warna Kuku (Kaki/Tangan) :.............................................

c. Edema (Kaki/Tangan) :.............................................

d. Refleks Tungkai Bawah :.............................................

e. Varises :.............................................

15. Vulva

a. Edema :..........................................

b. Varises :..........................................

c. Luka :...........................................

d. Pengeluaran cairan:............................................

e. Warna :.............................................

16. Rectum

varises :.....................................................................

Masalah Keperawatan :

VI. PEMERIKSAAN KHUSUS

1. Laboratorium
 a. Urine :...............................................

Test Kehamilan :................................................

b. Darah :................................................

WR :.................................................

HB / GoL Darah :.................................................

2. Diagnostik Kehamilan :...................................................................................

Yang Melakukan Pengkajian

(...........................................)

NIM.
 Nama Mahasiswa :.......................................................

NIM :.......................................................

Mata Kuliah :........................................................

ANALISA DATA

KEMUNGKINAN
NO DATA MASALAH
PENYEBAB/WOC
 DIAGNOSA KEPERAWATAN

NO TGL/JAM DIAGNOSA KEPERAWATAN PARAF

 PELAKSANAAN TINDAKAN KEPERAWATAN

NO DX TGL/JAM TINDAKAN KEPERAWATAN PARAF

 EVALUASI

MASALAH TGL/
CATATAN PERKEMBANGAN PARAF
KEPERAWATAN JAM
S:

O:

P
 KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN
PRODI PROFESI NERS
Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816

FORMAT PENGKAJIAN KELUARGA BERENCANA

TANGGAL PENGKAJIAN: NAMA MAHASISWA/I:

TANGGAL MASUK RS : NIM :

NO.REGISTER : TANDA TANGAN :

RUANGAN :

I. BIODATA

1. Nama :.........................................................................................
2. Umur :..............................................Pendidikan.........................
3. Suku Bangsa :.........................................................................................
4. Alamat :.........................................................................................
...............................................................................................................................................
5. Nama Suami :.........................................................................................
6. Agama :.........................................................................................
7. Pekerjaan :.............................................................................
............

II. RIWAYAT KESEHATAN

1. Keluhan Utama/Alasan datang ke PKM.........................................................................

2. Riwayat Kesehatan Sekarang:.........................................................................................

...............................................................................................................................................
...............................................................................................................................................
3. JUMLAH ANAK

NO Tanggal lahir anak Tipe persalinan Keadaan Ket

sekarang

1
2
3
4

4. Menstruasi Terakhir :…………………………………………………………………

5. Lama Perkawinan :………………………………………………………………….

6. Masalah waktu hamil :………………………………………………………….

7. Masalah setelah melahirkan :………………………………………………………

8. Riwayat Kontrasepsi

a. Apakah sudah pernah memakai alat kontrasepsi sebelumnya :

……………………………………………………………………………………

b. Memakai alat kontrasepsi jenis apa :……………………………………………….

c. Adakah masalah dengan menggunakan metode KB tersebut :

……………………………………………………………………………………

Jika ya , sebutkan :

9. Riwayat Kesehatan :

a. Masalah kesehatan yg dialami saat ini :………………………………………..

b. Apakah dalam pengobatan:……………………………………………………

c. Apakah pernah menderita infeksi vagina / panggul:………………………..

10. Rencana metode kontrasepsi yang akan digunakan klien dan pasangan :
……………………………………………………………………………………..

11. Analisa data

12. Diagnosa Keperawatan, NCP,Implementasi dan Evaluasi ( sesuai format askep)