PROGRAM STUDI ILMU KEPERAWATAN

STIKES FORT DE KOCK BUKITTINGGI

KEPERAWATAN MATERNITAS
PENGKAJIAN ANTENATAL

1. DATA UMUM
Nama Klien : ……………………
Umur : ……………………
Alamat : ……………………
Status Perkawinan : ……………………
Pendidikan : ……………………
Pekerjaan : ……………………
Agama : ……………………
Suku Bangsa : ……………………
Nama Suami : ……………………
Umur Suami : ……………………
Pekerjaan : ……………………
Tanggal Masuk : ……………………
Tanggal Pengkajian : ……………………

2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT DAHULU

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4. RIWAYAT PENYAKIT KELUARGA

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5. RIWAYAT GINEKOLOGI
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Genogram:
6. RIWAYAT OBSESTRI
1. Menstruasi
a) Menarche:
b) Siklus menstruasi :
c) Karakteristik :

2. G.....P.....A.....H...
a) HPHT :
b) Usia kehamilan :

3. Keluhan yang muncul selama kehamilan ini

Trimester Keluhan
I

II

III

4. Riwayat kehamilan dan pepuskesmasalinan yang lalu

No Tahun Tipe Lama/ Tempat/ BBL Kondisi Saat Masalah Komplikasi
Lahir Pepuskesma Proses Penolong Lahir Nifas & Selama
salinan Pepuskesma Pepuskesma Laktasi Kehamilan
salinan salinan

VII. KEBIASAAN YANG MERUGIKAN

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VIII. IMUNISASI
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IX. KEBUTUHAN DASAR

a. Nutrisi
i. Pola makan, frekuensi, jenis, jumlah
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 ii. Perubahan pola makan selama hamil
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iii. Alergi makanan

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iv. Keluhan yang berhubungan dengan nutrisi

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b. Eliminasi
i. Buang air kecil
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ii. Buang air besar
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c. Aktifitas dan latihan

i. Aktifitas selama hamil
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ii. Keluhan dalam beraktivitas
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d. Istirahat dan tidur

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e. Seksualitas
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f. Pepuskesmasepsi dan kognitif

i. Status mental : ...............................................................................................
ii. Sensasi
1). Pendengaran : ................................................................................................
2). Berbicara : ................................................................................................
3). Penciuman : .................................................................................................
4). Perabaan : ................................................................................................
5). Kejang : ................................................................................................
 6). Nyeri : ................................................................................................

g. Pepuskesmasepsi dan konsep diri

i. Motivasi terhadap kehamilan
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ii. Efek kehamilan terhadap body image
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iii. Orang yang paling dekat
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X. Keluarga Berencana
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XI. Pemeriksaan Fisik

a. Tanda-tanda vital
1.Tekanan darah :
2.Nadi :
3.Temperatur :
4.Respirasi rate :

b. Status gizi
1. Berat badan :
2. Tinggi badan :

c. Kepala, Leher :
Kepala
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Kesimpulan masalah keperawatan : ..................................................

Mata
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Kesimpulan maslah keperawatan : ....................................................
Hidung
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................

Kesimpulan masalah keperawatan : ..................................................

Telinga
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Kesimpulan masalah keperawatan : ..................................................

Mulut
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Kesimpulan masalah keperawatan : ..................................................

Leher
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Kesimpulan masalah keperawatan : ..................................................
Dada
Paru – paru
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Perjusi : .................................................................................
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Ausultasi : .............................................................................
 Jantung
Inspeksi : ..............................................................................
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Palpasi : ..............................................................................
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Perkusi : .................................................................................
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Auskultasi : .............................................................................
Kesimpulan masalah keperawatan : ..................................................
d. Abdomen :
 Uterus
 Tinggi fundus uterus : cm, Kontraksi : ya / tidak
 Leopod I :

 Leopod II :

 Leopod III :

 Leopod IV :

 Pigmentasi
 Lineanigra :
 Stariae :
 Fungsi pencernaan :
Masalah keperawatan :

e. Perineum & Genital :

Vagina : varises : ya / tidak
Kebersihan :
Keputihan :
 Jenis / warna :
 Konsistensi :
 Bau :
Hemoroid :
 derajat : lokasi :
 berapa lama : nyeri : ya / tidak
Masalah keperawatan :
 f. Ekstremitas
 Ekstremitas atas :
Edema : Ya / Tidak , Lokasi :
Varises : Ya / Tidak , Lokasi :
 Ekstremitas bawah :
Edema : Ya / Tidak , Lokasi :
Varises : Ya / Tidak , Lokasi :
Tanda Homan : + / -
Masalah keperawatan :

Pemeriksaan Laboratorium atau Hasil Pemeriksaan Diagnostik Lainnya

Tanggal dan Jenis Hasil Pemeriksaan dan Nilai Interpretasi

Pemeriksaan Normal

Terapi Medis yang Diberikan

Tanggal Jenis Terapi Rute Terapi Dosis Indikasi Terapi

Data Fokus :
Data Objektif Data Subjektif

Analisa Data
No Data Etiologi (berdasarkan Masalah
patofisiologi) keperawatan
1 DO:

DS:

2 DO:
 DS:

3 DO:

DS:

Diagnosa keparawatan
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2. ........................................................................................................................................................
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Perencanaan
SDKI SLKI SIKI
1 .....................
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3......................

Implementasi
Implementasi EVALUASI
(SOAP)
Diagnosa (Disertai Waktu)
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