PENGKAJIAN ANTENATAL CARE

Nama Mahasiswa : Tanggal Pengkajian :

NIM : RS/Ruangan :

I. DATA UMUM
Inisial Pasien : Nama Suami :
Umur : Umur :
Pekerjaan : Pekerjaan :
Pendidikan Terakhir : Pendidikan Terakhir :
Agama : Agama :
Suku Bangsa :
Status perkawinan :
Alamat :

II. DATA UMUM KESEHATAN

a. Keluhan Utama/Tujuan Kunjungan ANC :

b. Riwayat keluhan Utama :

c. Riwayat kesehatan Saat Ini :

d. Riwayat kesehatan keluarga (Genogram ):

III. PERSEPSI, HARAPAN DAN PSIKOLOGIS KLIEN SEHUBUNGAN DENGAN
KEHAMILAN
a. Perubahan fisik selama kehamilan
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b. Perubahan psikologis selama kehamilan
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c. Dukungan Keluarga
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d. Rencana melahirkan
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e. Rencana ASI Ekslusif/PASI
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f. Riwayat dan Rencana KB
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g. Pelajaran yang diinginkan saat ini :

 relaksasi/pernafasan/manfaat ASI/cara memberi minun/senam nifas/metoda
KB/perawatan perineum/perawatan payudara (Lingkari salah satu atau lebih)
lain-lain ..........................................................................................................................

h. Harapan klien terhadap kehamilannya

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i. Upaya dalam meningkatkan ikatan antara ibu, ayah, sibling dengan bayi
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a. Upaya keluarga dalam menyiapkan kebutuhan terhadap kehamilan
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b. Persiapan menjadi orang tua

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III. DATA UMUM OBSTETRI

a. Kehamilan sekarang direncanakan (ya/tidak) jelaskan :
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b. Status Obstetric :
G P A H...........................................................................................................

c. HPHT :
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d. Taksiran partus : (gunakan rumus perhitungan )

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e. Taksiran Berat janin : (gunakan rumus perhitunga TBJ)
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f. Mengikuti kelas prenatal (senam hamil ), frekuensi, lama, dan tempat

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g. Jumlah kunjungan ANC

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j. Riwayat Imunisasi TT
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h. Riwayat Persalinan
Kehamil Jenis Gangguang Cara Masalah Penolong Masalah Masalah Keadaan
an Ke- Kelamin pada saat Persalinan dalam Persalinan saat pada Anak
hamil Persalinan Nifas Bayi
1
2
3
4
5
6

IV. KEBUTUHAN DASAR KHUSUS

Menggambarkan kebutuhan dasar ibu sebelum dan selama kehamilan
a. Kenyamanan Istirahat Tidur
1. Ketidaknyamanan
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2. Istirahat dan Tidur
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3. Hygiene Prenatal
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b. Keselamatan
1) Pergerakan
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2) Penglihatan
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3) Pendengaran
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c. Nutrisi
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d. Gaya Hidup (kebiasaan/Pola hidup)
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 e. Eliminasi
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f. Oksigenasi
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g. Seksualitas
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V. PEMERIKSAAN FISIK (HEAD TO TOE)
a. Antropometri
TB :…………………………………………………………………
BB Sebelum Hamil :…………………………………………………………………..
BB Saat Ini :…………………………………………………………………
Lingkar Lengan :…………………………………………………………………..
b. Tanda Vital : TD : , Nadi : , Respirasi : Suhu :
c. Keadaan Umum :…………………………………………………………………..
d. Kepala :…………………………………………………………………
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e. Mata :…………………………………………………………………..
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f. Hidung: :…………………………………………………………………
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g. Telinga :…………………………………………………………………..
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h. leher :…………………………………………………………………
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 i. Jantung :.....................................................................................................
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j. Paru-paru :…………………………………………………………………
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k. Payudara :…………………………………………………………………
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l. Abdomen (secara umum dan pemeriksaan obstetrik)

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m. Perianal :………………………………………………………………….......................
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n. Anus :…………………………………………………………………
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o. Ekstremitas :…………………………………………………………………..
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p. Kulit, Kuku :…………………………………………………………………..
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q. Refleks Patella :…………………………………………………………………
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VI. PEMERIKSAAN PENUNJANG

Tanggal :…………………………………………………………………………
USG : Kesan …………………………………………………………………..
Laboratorium : Hasil……………………………………………………………………

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Gorontalo,
Mahasiswa Yang Mengkaji

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Nim :
VII. KLASIFIKASI/PENGELOMPOKKAN DATA BERDASARKAN GANGGUAN
KEBUTUHAN
1. Keluhan (Data Subjektif)

2. Data objektif
ANALISA DATA BERDASARKAN PATOFISIOLOGI DAN PENYIMPANGAN KDM

Penyakit (Diagnsa Medis) Klien :

Respon utama :

Penyimpangan KDM : (Bagan Sistematis)

RUMUSAN DIAGNOSA KEPERAWATAN

(Rujukan Diagnosa SDKI)