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SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA FORMAT PENGKAJIAN ANTENATAL KEPERAWATAN MATERNITAS Nama Mahasiswa :…………..

Tanggal Masuk Ruang /Kelas

……………. …………

Pengkajian tanggal ……………

A.

NIM :…………………….

Jam Masuk ……………………….. Kamar No Jam

…………………….. ……………………..

IDENTITAS

Nama Pasien

:……………

Nama Suami

Umur

:……………

Umur

:……… ….

Suku Bangsa

………..

Suku Bangsa

:…………..

Agama

………….

Agama

:………….

Pendidikan

:……… ………

Pendidikan

:………… …

Pekerjaan

:……………

Pekerjaan

:………… …..

Alamat Rumah

:………………

Alamat Rumah

:………………

Status Perkawinan :……………… B.

:………………

Status Perkawinan :………………

RIWAYAT KEPERAWATAN

1. Riwayat Obstetri a. Riwayat Menstruasi Menarche umur :…………… ……….

Siklus :…………………… ………

Banyaknya :…………………… …..

Lamanya ………………………

HPHT :…………… ……………..

Keluhan :……………………….

b. Riwayat Kehamilan, persalinan dan Nifas Anak ke

Kehamilan

N

Ta

Umur

Penyul

o

hu

Kehamil

it

n

an

Persalinan Jenis

Komplikasi nifas

Anak

Penol

Penyul

Laser

Infeks

Perdara

ong

it

asi

i

han

Jenis

B

PJ

B

c. Kehamilan Sekarang 

Diagnosa Kehamilan :................................................................



Usia Kehamilan :............................................................................



Imunisasi



ANC :................................................................................



Keluhan selama hamil dan keluhan saat ini :................................



Pengobatan selama hamil :...........................................................



Pergerakkan janin ...........................................................................



Rencana perawatan bayi

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

( ) sendiri

(

) orang tua

lain 

Keterangan.......................................................................................



Kesanggupan dan pengetahuan dalam merawat bayi :........



Breast care :..................................................



Perineal care :.............................................................



Nutrisi :............................................................



Senam nifas : .....................................................................



KB :........................................................................



Menyusui : ....................................................................

(

) lain

a. Riwayat Keluarga Berencana 1.

Melaksanakan KB : (…. ) Ya (……)Tidak

2.

Bila ya jenis kontrasepsi apa yang digunakan……..........…

3.

Sejak kapan menggunakan kontrasepsi………………….…

4.

Masalah yang terjadi………………… b. Riwayat Kesehatan

a.

Penyakit yang pernah dialami Ibu……………………...……..

b.

Pengobatan yang didapat…………… 1. Riwayat penyakit keluarga……………………….. 2. Keterangan : ……………………..…………..

c.

Riwayat Lingkungan 1. Kebersihan…………………………………………………… 2. Bahaya…………………………………………………..

3. Lainnya. Sebutkan………………………………………………… …………………………………………………………………………. c.

Aspek Psikososial

1.

Apakah kehamilan ini direncanakan oleh ibu dan pasangan ??.........

2.

Harapan yang ibu inginkan selama kehamilan.............................................

3.

Bagaiman dukungan pasangan terhadap kehamilan ini......................

4.

Bagaimana sikap anggota keluarga lainnya terhadap kehamilan ini............

5.

Lainnya. Sebutkan.....................................................................

d.

Kebutuhan Dasar Khusus

Pola Nutrisi 

Frekuensi makan............................................................................



Nafsu makan Jenis makanan rumah.......................................................



Makanan yang tidak disukai/ alergi pantangan

Pola eliminasi BAK 

Frekuensi ..................................................................................



Warna.........................................................................................



Keluhan saat BAK............................................................................

BAB 

Frekuensi .......................................................................................



Warna...............................................................................................



Bau...............................................................................................



Konsistensi..........................................................................................



Keluhan................................................................................................

.......................................................................................................................................... ........ Pola personal hygiene 

Mandi..................................................................................................



Oral Hygiene...................................................................................



Cuci Rambut.............



Lainnya.........................................................................................

Pola istirahat dan tidur 

Lama tidur.....................................................................



Kebiasaan sebelum tidur...............................................



Keluhan.........................................................................

............................................................................................................................................. ......... Pola aktifitas dan latihan............................................................ 

Kegiatan dalam pekerjaan........................................................................



Waktu bekerja......................................................................................



Olah raga...........................................................................................



Frekuensi.................................................................................................



Kegiatan waktu luang........................................................................

Keluhan dalam aktivitas.................................................. Kebiasaan yang mempengaruhi kesehatan 

Merokok...................................................................



Minuman keras........................................................................................



Ketergantungan obat.........................................................

e. PEMERIKSAAN FISIK Keadaan umum :………………

Kesadaran………

Tekanan darah:………………

Nadi …………………

Respirasi:………………… …………

Suhu ……………………………

Berat Badan:……………………….

Tinggi Badan ………………

Mata  Kelopak mata..................................................................  Gerakkan mata.......................................................................  Konjungtiva..............................................................................  Sklera.................................................................................................  Pupil.................................................................................................  Akomodasi...............................................................................................  Lainnya. Sebutkan.................................................................................... Hidung 

Reaksi allergi



Sinus..........................................................................................................



Lainnya.......................................................................................

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

Mulut dan Tenggorokkan 

Gigi geligi..............................................................



Kesulitan menelan Lainnya..............................................................................................

Dada & Aksila 

Mammae : ..............................................................................



Aerolla mammae.................................................................................



Papila mammae



Colostrum...............................................................................................

Pernapasan 

Jalan napas...............................................................................................



Suara napas................................................................................



Penggunaan otot bantu pernapasan........................................................

Sirkulasi Jantung 

Frekuensi nadi..........................................................................................



Irama................................................................



Kelainan bunyi jantung..................................................................



Keterangan :..........................................................................................

Abdomen 

Membesar…………………………………………………………….



Linea…………………………………………………



Striae…………………………………………………………………….



Leopold 1……………………………………………………………..



Leopold II…………………………………………………….



Leopold III……………………………………………………



Leopold IV………………………………



DJJ…………………………………………………………………………………… ….

Genital 

Keputihan………………………………………………………………..



Pap Smear……………………………………………………………….



Lainnya……………………………………………………………………………… …….

Ekstrimitas  Turgor kulit………………………………………………...  Warna kulit………………………………………………  Kesulitan dalam pergerakkan…………………  Lainnya…………………………………………………………………………….. d. 

DATA PENUNJANG Laboratorium………………………………………………………………………….

…………………………………………………………………………………………… ………….………………………………………………………………………………… ….



USG………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ………………………………



Terapi yang didapat…………………………………………

…………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ………………………………………….

e.

DATA TAMBAHAN

……………………………………………………………………………………………………… …………………………………………………………… Surabaya,…………………….. Pemeriksa……………………. (………………………………)

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