FORMAT ASKEP IBU HAMIL (ANC)

PENGKAJIAN

I. IDENTITAS

Nama ibu : Nama suami :

Umur : Umur :
Pendidikan : Pendidikan :
Agama : Agama :
Pekerjaan : Pekerjaan :
Status perkawinan :
Alamat :

Tanggal pengkajian :

Diagnosa medis :

2. DATA SUBJEKTIF

a. keluhan utama
.....................................................................................................................................................
.........................................................................................................................

b. riwayat Kesehatan Sekarang

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

c. Riwayat Kehamilan Sekarang

ANC(Ante Natal Care) :.........................teratur/tidak.................................................

Diperiksa : ..............................................................................................

Imunisasi :.............................................................................................

Usia kehamilan : .............................................................................................

d. Riwayat Menstruasi

Menarche : ....................siklus......................lamanya..........teratur/tidak.

Jumlah :......................Warna:..................dismenorhe:.....................

HPHT :......................taksiran persalinan ..............

 e. Riwayat obsteri

G.............................P.................................A......................................

RIWAYAT PERSALINAN

ANAK JENIS UMUR LAHIR USIA PENOLONG PENYULIT BBL KET

KE KELAMIN HAMIL

f. Riwayat Kesehatan / Penyakit Yang lalu :

Penyakit
Alergi
Merokok dan obat-obatan
g. Riwayat penyakit Keluarga

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

h. Keadaan Psikososial

Perubahan kehamilan terhadap kehidupan sehari-hari.

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

Harapan yang didinginkan selama kehamilan

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

Ibu tinggal serumah dengan siapa

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

Yang menemani ibu ke klinik

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

Rencana melahirkan
...........................................................................................................................

Rencana menyusui
...........................................................................................................................

i. Seksual
 Dampak kehamilan terhadap perubahan pola
seksual ......................................................................................................................
............

j. riwayat keluarga Berencana

 Jenis kontrasepsi yang pernah digunakan

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

 Masalah-masalah yang dailami selama kehamilan

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

 Jumlah anak yang direncanakan

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

k. Pola kehidupan sehari-hari

 Pola makan
 Diet kebiasaan (jenis)
............................................................................................................................

 Perubahan dalam pola makan

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

 Pandangan selama kehamilan terhadap makanan

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

 Masalah mengunyah/menelan
............................................................................................................................

 Kenyamanan, aktivitas dan istirahat

 Kenyamanan selama kehamilan dan cara mengatasinya
............................................................................................................................

 Aktivitas/hobi kebiasaan
............................................................................................................................

 Aktivitas kesenangan
............................................................................................................................
Pembatasan selama kehamilan kondisi

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

 Perubahan istirahat, tidur,dan cara mengatasinya

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

Jumlah jam istirahat/ tidur perhari

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

Pola eleminasi

Buang Air Besar

 Dampak kehamilan terhadap pola eleminasi

 Frekuensi BAB :...............x/ hari
 Nyeri/ rasa panas saat BAB :
 Perdarahan: Haemoroid:
Konstipasi : Diare :

Buang Air Kecil

 Frekuensi BAK :...............x/hari

 Kesulitan Berkemih: Riwayat Penyakit Ginjal:
Dorongan berkemih: Penggunaan diuretik :

 Personal hygiene
 Frekuensi mandi :...................X/hari
 Frekuensi gosok gigi :...................x/hari
 Perawatan Payudara :......................
 Vulva Hygiene :......................

3. PEMERIKSAAN FISIK

a. secara umum

Tanda- tanda vital

 Tekanan darah :......................................mm/Hg
 Suhu :......................................C
 Nadi :......................................x/ menit
 Pernapasan :......................................x/ menit
Berat badan sekarang :......................................Kg
Berat Badan sebelum lahir:.......................... . . . . .Kg
LILA :......................................Cm
b. Secara head To Toe

Kepala
 Rambut :...........................
 Muka :...........................
 Mata/ konjungtiva :...........................
 Hidung :...........................
 Mulut :...........................
Leher
 Inspeksi : Gondok :................................
  Palpasi : Masa :..........................................................
 Auskultasi : Bruit Aorta :..........................................................
Dada
 Payudara membersar :.......................
 Puting susu :.......................
 Kebersihan :.......................
 Simetris :.......................
Abdomen
 Inspeksi
 Striae Gravidarum :....................................
 Hiperpigmentasi :....................................
 Auskultasi
 DJJ :.....................................
 Bising usus :.....................................
 Palpasi
 Leopold I :.....................................

 Leopold II :.....................................
 Leopold III :.....................................
 Leopold IV :.....................................

 Perkusi :.....................................

Ekstremitas
 Kekuatan otot :.....................................
 Reflek Patela :.....................................
 Reflek Babinski :.....................................
 Edema :.....................................
 Chubb :.....................................
c. pemeriksaan laboratorium

 HB :...........................Gol. Darah
:...............................................Rh+/-
 Urine :..........................................................................................................
 USG :......................................................................................................
....
d. Data penunjang therapy

........................................................................................................................................................
........................................................................................................................................................
..............................................................................................................
ANALISA DATA

DATA PENYEBAB MASALAH

DO

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

DS

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

RENCANA INTERVENSI

PERENCANAAN
NO DIAGNOSA TUJUAN RASIONALISASI
KRITERIA
INTERVENSI
HASIL

IMPLEMANTASI DAN EVALUASI

NO. DIAGNOSA HARI/TANGGAL TINDAKAN EVALUASI