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 ):

GENOGRAM KELUARGA

III. PERSEPSI, HARAPAN DAN PSIKOLOGIS KLIEN SEHUBUNGAN DENGAN

KEHAMILAN
a. Perubahan fisik selama kehamilan
____________________________________________________________________
____________________________________________________________________
b. Perubahan psikologis selama kehamilan
____________________________________________________________________
____________________________________________________________________
c. Dukungan Keluarga
____________________________________________________________________
____________________________________________________________________
d. Rencana melahirkan
____________________________________________________________________
____________________________________________________________________
e. Rencana ASI Ekslusif/PASI
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
 f. Riwayat dan Rencana KB
____________________________________________________________________
____________________________________________________________________

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
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
i. Upaya dalam meningkatkan ikatan antara ibu, ayah, sibling dengan bayi
1. Upaya keluarga dalam menyiapkan kebutuhan terhadap kehamilan
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. Persiapan menjadi orang tua
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

2. DATA UMUM OBSTETRI

a. Kehamilan sekarang direncanakan (ya/tidak) jelaskan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

b. Status Obstetric :
G P A H______________________________________________________
 c. HPHT :
____________________________________________________________________
d. Taksiran partus : (gunakan rumus perhitungan )
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
e. Taksiran Berat janin : (gunakan rumus perhitunga TBJ)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
f. Mengikuti kelas prenatal (senam hamil ), frekuensi, lama, dan tempat
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
g. Jumlah kunjungan ANC
____________________________________________________________________
h. Riwayat Imunisasi TT
____________________________________________________________________
____________________________________________________________________
i. Riwayat Persalinan
Kehamil Jenis Gangguan Cara Masalah Penolong Masalah Masalah Keadaan
an Ke- Kelamin pada saat hamil Persalinan dalam Persalinan saat pada Anak
Persalinan Nifas Bayi
1
2
3
4
5
6
3. KEBUTUHAN DASAR KHUSUS
Menggambarkan kebutuhan dasar ibu sebelum dan selama kehamilan
a. Kenyamanan Istirahat Tidur
1. Ketidaknyamanan
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2. Istirahat dan Tidur
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

3. Hygiene Prenatal
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

b. Keselamatan
1) Pergerakan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2) Penglihatan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3) Pendengaran
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Nutrisi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

d. Gaya Hidup (kebiasaan/Pola hidup)

____________________________________________________________________
____________________________________________________________________
 ____________________________________________________________________
____________________________________________________________________

e. Eliminasi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
f. Oksigenasi
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
g. Seksualitas
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

4. 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 :
____________________________________________________________________
____________________________________________________________________
e. Mata :
____________________________________________________________________
____________________________________________________________________
f. Hidung :
____________________________________________________________________
____________________________________________________________________
g. Telinga :
____________________________________________________________________
____________________________________________________________________
h. Leher :
____________________________________________________________________
____________________________________________________________________
i. Jantung :
____________________________________________________________________
____________________________________________________________________
j. Paru-paru :
____________________________________________________________________
____________________________________________________________________
k. Payudara :
____________________________________________________________________
____________________________________________________________________
l. Abdomen (secara umum dan pemeriksaan obstetrik)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
m. Perianal :
__________________________________________________________________________
__________________________________________________________________________
n. Anus :
__________________________________________________________________________
__________________________________________________________________________
o. Ekstremitas :
__________________________________________________________________________
__________________________________________________________________________
p. Kulit, Kuku :
____________________________________________________________________
____________________________________________________________________
q. Refleks Patella :
__________________________________________________________________________
__________________________________________________________________________
5. PEMERIKSAAN PENUNJANG
Tanggal :________________________________________________________________
USG : Kesan___________________________________________________________

Laboratorium
Tanggal :________________________________________________________________

Pemeriksaan Hasil Satuan Nilai Rujukan

6. 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)
 PENGKAJIAN KLINIK KELUARGA BERENCANA

1. Initial Klien :
2. Status Perkawinan :
3. Jumlah Anak :

Tgl Tipe Pengguanaan

No. Keadaan Sekarang
Lahir/Umur Persalinan KB Setelah Persalinan
1.
2.
3.
4.
5.

4. Alasan Datang ke Klinik :

________________________________________________________________________
________________________________________________________________________
5. Menstruasi Terakhir :
________________________________________________________________________
________________________________________________________________________
6. Lama Perkawinan :
________________________________________________________________________
________________________________________________________________________
7. Masalah untuk hamil :
________________________________________________________________________
________________________________________________________________________
8. Masalah Dalam Kehamilan :
________________________________________________________________________
________________________________________________________________________
9. Masalah Setelah Melahirkan :
a. Apakah sudah pernah memakai alat kontrasepsi sebelumnya ?
__________________________________________________________________________
__________________________________________________________________________
 b. Adakah masalah dengan menggunakan metode tersebut ?
__________________________________________________________________________
__________________________________________________________________________
10. Riwayat Kesehatan
a. Apakah ibu merokok
__________________________________________________________________________
__________________________________________________________________________
b. Apakah ibu minum alkohol
____________________________________________________________________
____________________________________________________________________
11. Pengetahuan klien tentang KB
______________________________________________________________________________
______________________________________________________________________________
12. Rangkuman Masalah
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
13. Diagnosa keperawatan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________________
14. Rencana Tindakan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
15. Implementasi
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
16. Evaluasi
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
 PENGKAJIAN INTRANATAL CARE

A. IDENTITAS KLIEN
Nama :
Umur :
Alamat :
Agama :
Suku Bangsa :
Staus Perkawinan :
Pekerjaan :
Status Obstetri :

B. KELUHAN UTAMA/ALASAN MASUK RS

_______________________________________________________________________
_______________________________________________________________________

C. RIWAYAT KELUHAN UTAMA

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

D. KELUHAN SAAT INI

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

E. PENGKAJIAN AWAL

Tanggal : ________________Jam :_______________

Tanda vital :
Tekanan Darah ______mmHg
Frekuensi Nadi ______x/menit
Frekuensi Pernapasan _______x/menit
Suhu_____0C
Pemeriksaan palpasi abdomen
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Hasil periksa dalam
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Dilakukan klisma, (ya/tidak),jika ya, jelaskan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Pengeluaran pervaginam
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Perdarahan pervaginam (ya/tidak), jelaskan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Kontraksi uterus (frekuensi, lamanya, kekuatan)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Denyut jantung janin (frekuensi, kualitas)
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Status janin (hidup/tidak, jumlah, presentasi)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
F. KEADAAN UMUM
1. Kepala :
____________________________________________________________________
____________________________________________________________________
2. Mata :
____________________________________________________________________
____________________________________________________________________
3. Hidung :
____________________________________________________________________
____________________________________________________________________
4. Telinga :
____________________________________________________________________
____________________________________________________________________
5. Leher :
____________________________________________________________________
____________________________________________________________________
6. Jantung :
____________________________________________________________________
____________________________________________________________________
7. Paru-paru :
____________________________________________________________________
____________________________________________________________________
8. Payudara :
____________________________________________________________________
____________________________________________________________________
9. Abdomen (secara umum dan pemeriksaan obstetrik)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
10. Perianal :
__________________________________________________________________________
__________________________________________________________________________
 11. Anus :
__________________________________________________________________________
__________________________________________________________________________
12. Ekstremitas :
__________________________________________________________________________
__________________________________________________________________________
13. Kulit, Kuku :
____________________________________________________________________
____________________________________________________________________
14. Refleks Patella :
__________________________________________________________________________
__________________________________________________________________________

G. PERSALINAN KALA I
Mulai persalinan : tanggal_________ jam__________
Tanda dan gejala :________________________________________________________
Tindakan:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Observasi kemajuan persalinan

Tanggal/jam Kontraksi uterus DJJ Ket

Pengobatan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Lama kala I________ Jam______ Menit_______

Keadaan psikososial
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

H. PERSALINAN KALA II
Kala II dimulai : Tanggal__________ Jam_______
Tindakan:_________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Jelaskan upaya meneran:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Keadaan psikososial :
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Lama kala II__________ Jam________ Menit_______Detik_______
I. KALA III
Tanda dan gejala :____________________________________________________________
Tindakan:_________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Plasenta lahir jam : ______________________________________________________________________
Cara lahir plasenta:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Karakteristik Plasenta:_________________________________________________________
Panjang tali pusat______cm
Jumlah pembuluh darah____arteri____vena____
Pengeluaran Pervaginam____Ml
Jumlah laserasi : _____________________________________________________________
Karakteristik
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Psikososial
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Pengobatan
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
J. KALA IV
Mulai jam________
Tanda vital :
Tekanan Darah ______mmHg
Frekuensi Nadi ______x/menit
Frekuensi Pernapasan _______x/menit
Suhu_____0C
Tindakan:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Kontraksi uterus :_________________________________________________________

Perdarahan_____ml, Karakteristik____________________________________________

Bonding bayi dan ibu______________________________________________________

 PENGKAJIAN BAYI BARU LAHIR

A. IDENTITAS
Inisial Nama Ibu Bayi :
Tanggal / jam pengkajian :
Nama Ayah :
Pekerjaan :
Alamat :

B. KEADAAN BAYI BARU LAHIR

Lahir tanggal :_______________Jam :______
Sex :
Kelahiran :
Berat badan Lahir :
Panjang :____cm
Heat Rate :____x/menit
Pernapasan :____x/menit
Suhu : :____0c

C. NILAI APGAR

No Tanda 0 1 2 Jumlah

1. Frekwensi Tidak ada <100 100

jantung
2. Usaha nafas Tidak ada Lambat Menangis
kuat
3. Tonus otot Lumpuh Ekstremitas fleksi Gerakan aktif
sedikit
4. Refleks Tidak bereaksi Gerakan sedikit Reaksi
melawan
5. Warna kulit Biru pucat Tubuh kemerahan, Kemerahan
tangan dan kaki biru

Ket : penilaian menit ke 1 = ....... penilaian menit ke 5 = ........

 Tindakan resusitasi :________________________________________________

Tali pusat :________________________________________________

D. PENGKAJIAN FISIK
Umur :
Berat badan :_____ gr
Panjang :_____ cm
Antropometri :
BBL : _____ gr BB sekarang : _____ gr
PB : _____cm
LK : _____cm
LP : _____cm
LD : _____cm
LILA : _____cm
Tanda – Tanda Vital :
Frekuensi Nadi :
Pernapasan :
Suhu :

KEPALA & LEHER

1) Bentuk :
__________________________________________________________________
__________________________________________________________________

2) Ubun – ubun :
__________________________________________________________________
__________________________________________________________________

3) Mata :
__________________________________________________________________
__________________________________________________________________

4) Telinga :
__________________________________________________________________
__________________________________________________________________
5) Mulut :
__________________________________________________________________
__________________________________________________________________

6) Hidung :
__________________________________________________________________
__________________________________________________________________

7) Leher :
__________________________________________________________________
__________________________________________________________________

TUBUH
1) Warna :_________________________________________________________
2) Pergerakan :_____________________________________________________
3) Dada :_______________________________________________________
4) Vernik kaseosa :_____________________________________________________

JANTUNG DAN PARU

1) Waktu Pengisian kapiler :___________________________________________
2) Frekuensi denyut nadi/irama :___________________________________________
3) Bunyi nafas :___________________________________________
4) Frekuensi pernafasan :___________________________________________

PERUT DAN ABDOMEN

1) Gerakan diagpragmatik :_____________________________________________________

PUNGGUNG
1) Keadaan punggung :_______________________________________________
2) Lanugo :_______________________________________________

GENITALIA
1) Anus :_______________________________________________
2) Keadaan :_______________________________________________
EKTREMITAS
1) Jumlah jari tangan :
_______________________________________________
2) Jari kaki :
_______________________________________________
3) Pergerakan :
_______________________________________________
4) Garis telapak kaki :
_______________________________________________
5) Posisi kaki dan tangan :
_______________________________________________

STATUS NEUROLOGIS
Refleks – reflleks :
1) Tendon :
_______________________________________________
2) Moro :
_______________________________________________
3) Rooting :
_______________________________________________
4) Sucking : ______________________________________________
5) Babinski :
_______________________________________________
6) Palmar grapd :
_______________________________________________
7) Menangis :
_______________________________________________
8) Asymmetric tonic neck :
_______________________________________________

NUTRISI
1) Jenis makanan :
_______________________________________________
 2) Diberikan dengan :
_______________________________________________
3) Jumlah yang diberikan :
_______________________________________________

FORMAT PENGKAJIAN POSTNATAL

I. Data Umum Klien

1. Initial Pasien : Initial Suami :
2. Usia : Usia :
3. Status Perkawinan : Status perkawinan :
4. Pekerjaan : Pekerjaan :
5. Pendidikan Terakhir : Pendidikan terakhir :

Riwayat Kehamilan dan persalinan Yang Lalu

No Tahun Tipe Penolong Jenis BB Keadaan Masalah

Persalinan Kelamin lahir Bayi Waktu Kehamilan
Lahir
1
2
3
4
5
 Pengalaman menyusui : ya / tidak Lamanya :____________
Riwayat Kehamilan Saat Ini :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Beberapa Kali Periksa Hamil:

_______________________________________________________________________
Masalah Kehamilan:
________________________________________________________________________
________________________________________________________________________
Riwayat Persalinan
1. Jenis Persalinan : Spontan ( letkep/letsu)/Tindakan ( EF/EV )________
SC a/I________Tgl/ jam ________

2. Jenis Kelamin Bayi: L/P, BB/PB: ________Gram/________cm, A/S________

Perdarahan______cc
Masalah dalam Persalinan :
______________________________________________________________________
Riwayat Ginekologi :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Masalah Ginekologi :
______________________________________________________________________
______________________________________________________________________
Riwayat KB :
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________

II. Data Umum Kesehatan Saat Ini

Status Obstetrik : NH______P ______A ______
Keluahan Utama :_________________________________________________________
Riwayat Keluhan Utama
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Status Kesehatan Saat Ini

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Bayi Rawat Gabung: ya/tidak Jika tidak alasannya________________________

Keadaan umum: ________________________ Kesadaran: ________________________

BB :______kg
TB :______cm
Tanda Vital
Tekanan Darah ______mmHg
Frekuensi Nadi ______x/menit
Frekuensi Pernafasan ______x/menit
Suhu ______ºC

Pemeriksaan Head To Toe:

Kepala :
_______________________________________________________________________
_______________________________________________________________________
Mata :
_______________________________________________________________________
_______________________________________________________________________
Hidung :
_______________________________________________________________________
_______________________________________________________________________
Telinga :
_______________________________________________________________________
_______________________________________________________________________
Leher :
_______________________________________________________________________
_______________________________________________________________________
Jantung :
_______________________________________________________________________
_______________________________________________________________________
Paru-paru :
_______________________________________________________________________
_______________________________________________________________________
Puting susu :
_______________________________________________________________________
_______________________________________________________________________

Penyaluran ASI :
_______________________________________________________________________
_______________________________________________________________________
Abdomen (Involusi Uterus)
Fundus uterus:___________Kontraksi:___________Posisi:___________
Kandung Kemih:_________________________________________________________

Perianal
Vagina: Integritas kulit___________edema_______memar_______Hematom________
Perineum: Utuh/Episiotomi/Ruptur Tanda
REEDA:
R : Kemerahan : ya / tidak
E : Bengkak : ya / tidak
E : echimosis : ya / tidak
D : discharge : serum/pus/darah/tidak ada
A : approximate : baik / tidak
Kebersihan :________________________________________________________________
Lochea : _______________________________________________________________
Jumlah :________________________________________________________________
Jenis warna : _______________________________________________________________
Konsistensi : _______________________________________________________________
Bau : _______________________________________________________________
Hemorrhoid : derajat : ___________, Lokasi : ___________
Berapa lama nyeri : ya / tidak

Ekstremitas
Ekstremitas atas : edema : ya / tidak, rasa kesemutan/baal : ya/tidak
Ekstremitas bawah : edema : ya / tidak, lokasi__________
Varises : ya / tidak, lokasi___________________
Tanda Homan : +/-

Eliminasi
Urine : Kebiasaan BAK ___________________________________________________
BAK saat ini________________________________________________nyeri : ya / tidak
BAB : Kebiasaan BAB____________________________________________________
BAB saat ini_____________________________________________Kontipasi : ya/tidak

Istirahat dan Kenyamanan

Pola tidur : kebiasaan tidur, lama _____ jam, frekuensi_________
Pola tidur saat ini_________________________________________________________

Keluhan ketidaknyamanan: ya / tidak, lokasi____________________________________

Sifat ________________________ Insentitas ________________________

Mobilisasi dan latihan

Tingkat mobilisasi : _______________________________________________________
Latihan/senam : _______________________________________________________

Nutrisi dan Cairan

Asupan Nutrisi : ________________________Nafsu makan: baik/kurang/tidak ada
Asupan cairan :________________________cukup / kurang

Keadaan Mental
Adaptasi psikologis : _________________________________________________
 Penerimaan terhadap bayi : _________________________________________________

Kemampuan menyusui : _____________________________________________________

OBAT-OBATAN

No. Nama Obat Dosis Indikasi Kontraindikasi

PEMERIKSAAN PENUNJANG
Tanggal :________________________________________________________________
USG : Kesan___________________________________________________________

Laboratorium
Tanggal :________________________________________________________________

Pemeriksaan Hasil Satuan Nilai Rujukan

 FORMAT PENGKAJIAN GSR

A. Identitas Klien
1. Nama :
2. Umur :
3. Alamat :
4. Agama :
5. Suku Bangsa :
6. Status Perkawinan :
7. Pekerjaan :
8. Pendidikan :
9. Status Obstetri :

B. Keluhan Utama

_______________________________________________________________________

C. Riwayat Keluhan Utama

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

D. Riwayat Kesehatan Sekarang

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

E. Riwayat Kesehatan Keluarga (Genogram)

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
F. Riwayat Obstetri
Kehamilan Gangguang Cara Masalah Penolong Masalah Masalah Keadaan
Ke- Kehamilan Persalinan Persalinan Persalinan Nifas Bayi Anak

G. Riwayat Menstruasi
1. Manarche Usia :__________

2. Siklus Menstruasi :__________.hari, lama menstruasi_______hari

3. Adakah keluhan nyeri haid ? jika ya bagaimana cara mengatasinya

___________________________________________________________________
___________________________________________________________________

4. Banyaknya :____________________________________________________

H. Keluarga Berencana

1. Jumlah anak yang direncanakan :__________

2. Jenis kontrasepsi yang pernah digunakan :

No. Jenis Kontrasepsi Lama Penggunaan Keluhan Alasan ganti

 3. Adakah gangguang atau masalah dengan kontrasepsi tersebut, bila ada bagaimana
cara mengatasisnya
___________________________________________________________________
___________________________________________________________________

I. Kebutuhan Dasar Khusus :

1. Oksigenasi
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2. Nutrisi
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3. Cairan
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
4. Eliminasi
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5. Kenyamanan
___________________________________________________________________
___________________________________________________________________
6. Pengetahuan
___________________________________________________________________
___________________________________________________________________

J. Pemeriksaan Fisik (Head To Toe)

1. Antropometri
TB : ____________
BB Sebelum sakit : ____________
 BB Saat ini : ____________
Lingkar Lengan : ____________
2. Tanda Vital
Tekanan Darah : ____________
Nadi : ____________
Respirasi : ____________
Suhu : ____________

Kepala :
____________________________________________________________________
____________________________________________________________________
Mata :
____________________________________________________________________
____________________________________________________________________
Hidung :
____________________________________________________________________
____________________________________________________________________
Telinga :
____________________________________________________________________
____________________________________________________________________
Leher :
____________________________________________________________________
____________________________________________________________________
Jantung :
____________________________________________________________________
____________________________________________________________________
Paru-paru :
____________________________________________________________________
____________________________________________________________________
Payudara :
____________________________________________________________________
____________________________________________________________________
 Abdomen (secara umum dan pemeriksaan obstetrik)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Perianal :
____________________________________________________________________
____________________________________________________________________
Anus :
____________________________________________________________________
____________________________________________________________________
Ekstremitas :
____________________________________________________________________
____________________________________________________________________
Kulit, Kuku :
____________________________________________________________________
____________________________________________________________________
Refleks Patella :
____________________________________________________________________
____________________________________________________________________

K. Pengkajian Psikososial

1. Penerimaan Ibu terhadap penyakitnya

____________________________________________________________________
____________________________________________________________________
2. Dukungan Keluarga

____________________________________________________________________
____________________________________________________________________
3. Upaya keluarga dalam menyiapkan kebutuhan terhadap perubahan peran ibu

____________________________________________________________________
____________________________________________________________________
 4. Bagaimana perasaan ibu dengan perubahan peran karena proses penyakit dan

hospitalisasi

____________________________________________________________________
____________________________________________________________________

L. Pemeriksaan Penunjang
Tanggal :________________________________________________________________
USG : Kesan___________________________________________________________

Tanggal :________________________________________________________________
Urinalis : Hasil____________________________________________________________

Laboratorium
Tanggal :________________________________________________________________

Pemeriksaan Hasil Satuan Nilai Rujukan

M. Therapy (Oral, Injeksi, Kemotherapy, dll)

No. Nama Obat Dosis Indikasi Kontraindikasi