FORMAT PENGKAJIAN ANTENATAL
FORMAT PENGKAJIAN ANTENATALI. BIODATA
Nama klien:Umur
:
Suku/ bangsa:Agama
:
Pendidikan:
Pekerjaan:Alamat kantor:Alamat rumah:
Nama suami:
Umur
:Suku/ bangsa:
Agama
:
Pendidikan:
Alamat kantor:
II. AMNESATanggal
:
Jam:1. Keluhan utama
:2. Riwayat penyakit keseharian:3. Riwayat menstruasi
: Menarche: umur ........... tahun Siklus
: Banyaknya:
Dismenorea:
Keteraturan: Lamanya
: Sifat darah: HPHT
:4. Riwayat perkawinan: Status perkawinan:5. Riwayat Kehamilan
Yang
Lalu:(G...................,P...................,A..................)NoTgl/th
PartusUmur HamilJenisPersPenolongPenyuliAnakNifasKeadaanAnak
JenisBBI
1.2.
3.
Dst.
6. Riwayat kehamilan: Tri Mester I:ANC: ..................kali,
dengan,...................teratur/ tidakImunisasi:
Tri Mester II:
ANC:..................kali, dengan,...................teratur/
tidak
Imunisasi:
Keluhan:
Tri Mester III:
ANC:..................kali, dengan,...................teratur/
tidak
Imunisasi:
Keluhan:
7. Riwayat keluarga berencana:8. Riwayat penyakit sistemik:9.
Riwayat penyakit yang lalu/ riwayat operasi :10. Riwayat penyakit
keluarga:
11. Riwayat kebiasaan dan psikososial:
III. PEMERIKSAAN FISIK1. Pemeriksaan umum: Keadaan umum: Tekanan
darah:
Suhu
:
Berat badan:
Kesadaran:
Nadi
:
Pernafasan:
Tinggi badan:
2. Pemeriksaan head to toe KepalaRambut
:Mata
:
Skelera
:Muka
:
Mulut/ Gigi:
Telinga
LeherKelenjar gondok/ tiroid:
Tumor
: Dada dan aksilaMamae : membesar ;
............................. tumor
;..............................simetris;
........................ Areola
;......................................... putting susu ;
................................. kolostrum
;.................................................
Sriae ; .........................................
Axilla: tumor ......................... nyeri
..........................3. Abdomen:Inspeksi:
Pembesaran : ..................................... dengan arah :
memanjang/ melebar
Pelebaran vena : ....................................lenea alba/
nigra :................
Striae albican/ lividea :
......................................................................
Kelainan lain :
...................................................................................
Palpasi:
Leopold I : TFU
.......................................................................
FU terisi ............................................
Leopold II : batas samping kanan teraba :
........................................
Batas samping kiri teraba :
...............................................................
Leopold III : bagian bawah terisi
.....................................................
Leopold IV : tangan konvergen/ sejajar/ divergen
Taksiran berat janin (TBJ)
...............................................................
His : Frekuensi : ................................ Lama :
..................................
Kekuatan : ................................ Relaksasi :
............................Auskultasi:
DJJ : punctum maksimum : ...........................Tempat:
..........................................
Frekwensi : ........................................... Teratur/
tidak: ...............................
4. Ano genitalInspeksi :
Inspekulo : vagina :
..............................................................................................
Portio:
..............................................................................................Vaginal
toucher :
Vulva/ vagina: tumor/ varises/ lividea/ kelainan bawaan
Portio: arah : ............................................
penipisan: ................................................
Konsistensi : .................................pembukaan :
...........................................
Ketuban :
...................................................................................................................Bagian
bawah anak : teraba : ............................... Turun Hodge :
............................Dengan penunjuk :
....................................................................................................
Bagian lain yang teraba :
Ukuran panggul dalam :
Promontorium: teraba/ tidak :
Conjungata vera: ....................cm
Linea innominata:
Spina isciadicha:
Sacrum:
Os. Coccygis:
Arcus pubis:
Kesan panggul:
5. EkstremitasTungkai: simetris/ tidak : Oedema:
............................................. varices :
..............................................
Refleks patela : .........................................
kelainan lain : .....................................
IV. Pemeriksaan laboratoriumDarah : Hb .........................
gr %, gol darah : ...................................
Urine: protein : .................................., reduksi :
............................
V. Resume
keperawatan.....................................................................................................................................................................................................................................................................................................................................................................................................................
KEPERAWATAN MATERNITASPENGKAJIAN INTRANATAL
Nama Mahasiwa: .........................................NIM
: .....................Tempat Praktik:
......................................... Tanggal pengkajian:
.....................
I. DATA UMUM
Inisial klien: ..........................
Nama suami:.....................................Umur:
..........................
Umur:......................................Alamat:
..........................
Pekerjaan:......................................Agama:
........................... Pendidikan
terakhir:......................................Pekerjaan:
...........................Suku bangsa:
...........................
Status perkawinan: ...........................Pendidikan
terakhir: ...........................II. DATA UMUM KESEHATAN
1. Tinggi badan/ berat badan:
.......................................2. Berat badan sebelum
hamil: .......................................
3. Masalah kesehatan khusus:
.......................................4. Obat-obatan
: .......................................
5. Alergi (obat/makanan/bahan tertentu):
......................................
6. Diet khusus
: .......................................
7. Menggunakan (gigi tiruan/ kaca mata/ lensa kontak/ alat
dengar) : ................................8. Lain lain sebutkan:
.........................................9. Frekuensi BAK
: ....................................... kali/ hari
Masalah
: ......................................................
10. Frekuensi BAB
: ....................................... kali/ hari
Masalah
: ......................................................
11. Kebiasaan waktu tidur:
......................................................III. DATA
UMUM KEBIDANAN
1. Kehamilan sekarang direncanakan (ya/ tidak) :
..................................2. Status obsretikus:
G....................P...................A..................usiaKehamilan
........................... minggu3. HPHT:
...................................................................taksiranPartus
.....................................................4. Jumlah anak
di rumah;NoJenisCara LahirBB LahirKeadaan Umur
1.2.
3.
4.
5.
6.
5. Mengikuti kelas prenatal : (ya/ tidak)
6. Jumlah kunjungan pada kehamilan ini :
..........................................................................7.
Masalah kehamilan yang lalu :
..........................................................................8.
Masalah kehamilan yang sekarang :
..........................................................................
9. Rencana KB
:
..........................................................................10.
Makanan bayi sebelumnya : ASI/ PASI/lain-lain
.........................................11. Pelajaran apa yang
diinginkan saat ini: (lingkari) relaksasi, pernafasan/ manfaat ASI/
cara memberi minum botol/ senam nifas/ metode KB/ perawatan
perineum/ perawatan payudara12. Setelah bayi lahir, siapa yang
diharapkan membantu : suami/ teman/ orang tua
13. Masalah dalam persalinan yang lalu :
...........................................................................IV.
RIWAYAT PERSALINAN SEKARANG
1. Mulai persalinan (kontraksi/ pengeluaran pervaginaan) tgl/
jam ....................................2. Keadaan kontraksi
(frekuensi dalam 10 menit, lamanya,
kekuatan):...............................3. Frekuensu dan kualitas
denyut jantung janin :
..................................................x/ menit4.
Pemeriksaan fisik:Kenaikan BB selama kehamilan :
...............................................................................kg
Tanda-tanda vital :TD................... mmHg.
Nadi.......................X/mnt. Suhu...........C
P .................................x/menit
Kepala leher
(normal/tidak):..........................................................................................
Jantung:
.......................................................................................................
Paru-paru:
......................................................................................................
Payudara:
.......................................................................................................
.......................................................................................................
Kontraksi: .................................................DJJ
..............................................
Ekstemitas: (edema/ tidak)
...............................................................................
Refleks:
.......................................................................................................
5. Pemeriksaan dalam jam pertama :
.............................oleh............................................Hasil
:
...................................................................................................................
...................................................................................................................
6. Ketuban (utuh/ pecah), jika sudah pecah Tgl/
jam........................................................ warna
..........................................7. Laboratorium:
..........................................................................................................V.
DATA PSIKOSOSIAL1. Penghasilan keluarga setiap bulan:
............................................................................
2. Bagaimana perasaan anda terhadap kehamilan sekarang
....................................................................................................................................................................................................................................................................3.
Bagaimana perasaan suami anda terhadap kehamilan sekarang
....................................................................................................................................................................................................................................................................4.
Jelaskan respon sibling terhadap kehamilan sekarang
....................................................................................................................................................................................................................................................................
LAPORAN PERSALINANI. PENGKAJIAN AWAL
1. Tanggal: ...............................................jam :
..................................................2. Tanda-tanda
vital: TD ................... mmHg. Nadi .................. x/ mnt.
Suhu .............C
P .................................. x/mnt3. Pemeriksaan palpasi
abdomen:
......................................................................................4.
Hasil pemeriksaan dalam :
.............................................................................................
5. Persiapan perinium :
......................................................................................................6.
Dilakukan klisma; ya/ tidak, jelaskan
............................................................................
........................................................................................................................................
7. Pengeluaran pervaginaan
...............................................................................................8.
Perdarahan pervaginaan; ya/ tidak, jelaskan
..........................................................................................................................................................................................................
9. Kontraksi uterus (frekwensi, lamanya, kekuatan) :
.......................................................10. Denyut
jantung janin (frekwensi, kualitas):
..................................................................11.
Status janin (hidup/ tidak, jumlah, presentasi):
..............................................................
II. KALA PERSALINAN KALA I
1. Mulai persalinan tanggal:
............................................... jam
..........................................2. Tanda dan gejala
..............................................................................................................3.
Tanda-tanda vital:
............................................................................................................
4. Lama kala I: .............................. jam
............................... menit ...........................
detik5. Keadaan psikososial :
......................................................................................................
6. Kebutuhan khusus klien:
..................................................................................................7.
Tindakan :
.......................................................................................................................
.......................................................................................................................
8. Pengobatan:
.........................................................................................................OBSERVASI
KEMAJUAN PERSALINAN
Tanggal/ jamKontraksi UterusBJJKet
KALA II
1. Kala II mulai tanggal:
................................................ jam
..............................................
2. Lama kala II: .......................... jam
............................... menit
.............................. detik3. Tanda dan gejala :
............................................................................................................
4. Jelaskan upaya mengerang :
.............................................................................................
5. Keadaan psikososial :
.......................................................................................................6.
Tindakan :
........................................................................................................................
CATATAN KELAHIRAN1. Bayi lahir jam :
.................................................................................................................2.
Nilai APGAR : menit I ...................................... menit
V ...............................................3. Perinieum : ( )
utuh, ( ) episiotomi, ( ) ruptur, tingkat ....................4.
Bonding ibu dan bayi :
.....................................................................................................5.
Tanda-tanda vital : TD .................. mmHg. Nadi
................. x/mnt. Suhu ................ CP
.................................. x/mnt6. Pengobatan :
.....................................................................................................................KALA
III
1. Tanda dan gejala
..............................................................................................................2.
Plasenta lahir jam :
...........................................................................................................3.
Cara lahir plasenta :
.........................................................................................................4.
Karakteristik plasenta:Ukuran ............................. cm X
....................................cm X
..................................cmPanjang tali pusat
......................................................................................................
cmPembuluh darah ........................................... arteri
.................................................venaKelainan
..........................................................................................................................
5. Perdarahan : ........................................... ml,
karakteristik .............................................6.
Keadaan psikososial
........................................................................................................7.
Kebutuhan khusus klien :
................................................................................................8.
Tindakan :
.......................................................................................................................9.
Pengobatan
.......................................................................................................................KALA
IV1. Mulai jam :
......................................................................................................................2.
Jenis kelamin
...................................................................................................................3.
Nilai APGAR :
................................................................................................................4.
BB/ PB bayi: ............................................... gram
.................................................... cm5.
Karakteristik bayi
...........................................................................................................6.
Lingkar kepala :
..............................................................................................................7.
Kaput suksesaneum : ( ), chepalhematoma ( )8. Suhu :
.............................................. C
9. Anus : berlubang/ tertutup
10. Perawatan tali pusat :
......................................................................................................11.
Perawatan mata
...............................................................................................................LAPORAN
PARTUS NORMALSYAOR OBSTETRINama Klien:
Status Obstetrikus:Tanggal/ jamKeterangan
KEPERAWATAN MATERNITASPENGKAJIAN BAYI BARU LAHIRNama Mahasiswa :
......................................... Rumah Sakit:
....................................Nama Ayah-Ibu:
.......................................... Tanggal pengkajian :
.........................Alamat:
.......................................... Jam pengkajian :
................................
RIWAYAT KELAHIRAN YANG LALUNoTahun kelahiranSexBB
lahirKeadaan BayiKomplikasiJenisPersalinanKet
1.2.
3.
4.
5.
6.
STATUS GRAVIDA
G ................................. P
......................................... H
........................................ presentasiBayi
..............................................................................
Pemeriksaan antenatal : teratur/ tidak teratur
Komplikasi antenatal :
.................................................
RIWAYAT PERSALINAN
BB/ TB ibu ........................................... kg/
cmPersalinan di
...............................................................Keadaan
umum ibu .......................................... tanda vital
...................................................Jenis persalinan
: ........................................ proses kala persalinan I
............................ jamIndikasi :
........................................................................
Kala II ................................ menit
Komplikasi persalinan ibu
:........................................... fetus
...............................................Lamanya ketuban
pecah.............................................................................................kondisi
Ketuban...................................KEADAAN BAYI SAAT
LAHIRLahir
Tanggal............................................................jam...........................................................sex
Kelahiran : tunggal/gemelli.
NILAI APGAR
Tanda012Jumlah
Frekuensi Jantung
Usaha Nafas
Tonus Otot
Refleks
Warna Kulit( ) 0 Tidak ada
( ) 0 Tidak ada
( ) 0 Lumpuh
( ) 0 Tidak Bereaksi
( ) 0 Biru/Pucat( ) 0 < 100
( ) Lambat
( ) Ekstemitas fleksi sedikit
( ) 0 Gerakan Sedikit
( ) 0 tubuh kemerahan tangan dan kaki biru( ) 0 > 100
( ) 0 Menangis kuat
( ) 0 gerakan aktif( ) reaksi melawan
( ) 0 kemerahan
Ket ( ) peniloain menit ke 1 0 penilaian menit ke-5Tindakan
Resusitasi...............................................................................................................
Plasenta : Berat........................................... Tali
pusat :
Panjang.......................................................................
Ukuran................................................ Jumlah pemb.
Darah
..............................................................................................................Kelainan...............................................
Kelainan
.................................................................
PENGKAJIAN FISIK
Umur ..................................... hari
......................................jam.
Berat Badan g
Panjang badan cm
Suhu C
Lingkar kepala cm
Lingkar dada cm
Lingkar perut cm
KepalaBentuk 0 bulat 0 lain-lainKepala 0 molding 0 kaput 0
chepal hematomaUbun-ubun 0 besar ........................... 0
kecil ............................
0 sutura ..........................
Mata posisi ............................. bentuk
...........................
0 lubang telingan 0 keluaranJantung dan paru-paru
Bunyi nafas 0 Ngorok
0 Lain-lainPernafasan ..................................... x/
menitDenyut jantung ............................. x/ menitPerut 0
lembek 0 kembung
0 benjolan
Bising usus ...... x/menit
Lanugo
........................................................Vernik
.........................................................Mekonium
...................................................Punggung
Keadaan punggung 0 asimetris 0 pilonidal dimpleFleksibilitas
Tul. Punggung 0 kelainanGenetalia
Laki-laki 0 hypospadius 0 epispadiusTestis
..........................................................
PerempuanLabia minor 0 menonjol
0 tertutup labia mayor
Keluaran ......................
Anus 0 kelainanEkstremitasJari tangan 0 kelainan
................
Jari kaki 0 kelainan .................Pergerakan 0 tidak
aktif
0 asimetris
0 tremor 0 rotasi pahaNadi brachial .....................
femoral .....................Garis telapak kaki
......................................Posisi : kaki
.............................................
tangan .............................................Mulut 0
simetris
0 palatum mole 0 palatum durum 0 gigi Hidung 0 lubang hidung
0 keluaran
0 pernafasan cuping HidungLeher 0 pergerakan leher
Tubuh
Warna 0 pink 0 pucat
0 sianosis 0 kuning
Pergerakan 0 aktif
0 kurang
Dada 0 asimetris
0 retraksi 0 seasawStatus Neurologi
Refleks 0 Tendon 0 Moro 0 Rooting 0 Menghisap 0 Babinski 0
Mengenggam 0 Mengangis 0 Berjalan 0 Tonus leher
KEBUTUHAN DASAR SEHARI-HARI1. kebutuhan O22. kebutuhan
nutrisi
ASI
PASI
3. kebuthan istirahat tidur dan rasa nyaman4. kebutuhan
eliminasi
BAB pertama tanggal .......... jam ............BAK pertama
tanggal .......... jam ............
Jelaskan ...................................................
5. kebutuhan psikososial spiritual6. data penunjang
laboratorium : ..........................................terapi
: ..........................................
Resume ........................FORMAT PENGKAJIAN IBU POST
PARTUMNama mahasiswa: ......................................Tanggal
pengkajian: ....................................NIM:
......................................Ruang/ RS:
....................................
1. Data umum kesehatan
I. Identitas Klien1. Inisial klien:
...................................................................................................2.
Umur:
3. Pendidikan:
4. Pekerjaan:
5. Agama:
6. Alamat:
7. Tgl masuk:
8. Nama suami:
9. Umur:
10. Pendidikan:
11. Pekerjaan:
II. Riwayat kesehatanA. Riwayat kehamilan
Masalah pre natal:B. Riwayat menstruasi
Monorche
: Siklus
: Banyaknya
:
Lamanya
: Keteraturan
:
Keluhan yg menyertai:
C. Riwayat persalinan sekarang Tanggal persalinan:
.......................... jam ......................... Tipe
persalinan
: ..........................................................
Lama persalinan
: Kala I:jam
Kala II:jam
Kala III:jam
Total:jam
Jumlah perdarahan:
.......................................................... Jenis
kelamin bayi
: ........................ BB ......................PB Apgar
score
: menit I ............................... menit VD. Riwayat
obstetriNoKehamilan Persalinan Nifas
Usia KehamilanPenyu-litJenis
KelaminPenyu-litLaserasiInfeksiPerdarahanBB/PB
E. Riwayat keluarga berencana Jenis kontrasepsi Sejak kapan
menggunakan kontrasepsi
Masalah yang terjadi
Reencana KBF. Riwayat penyakit yang laluG. Riwayat penyakit
keluargaH. Riwayat kebiasaan sehari-hari1. Pola nutrisi
Frekuensi makanan Jenis kelamin
Makanan yang disukai/ alergi/ pantang
2. Pola eliminasiBAK: frekuensi
Warna
Keluhan saat BAKBAB: frekuensi
Warna
Bau
Konsistensi
Keluhan
Penggunaan laxatif/ pencahar3. Pola istirahat dan tidur Lama
tidur Kebiasaan sebelum tidur/ pengantar tidur Keluhan/ masalah
tidurI. Riwayat psikososial1. Sikap ibu terhadap kelahiran
bayinya2. Seikap anggota keluarga terhadap kelahiran bayinya
3. Kesiapan mental untuk menjadi ibu4. Rencana perawatan
bayi
5. Kesanggupan dan pengetahuan dalam merawat bayi
..............................................................................
..............................................................................
..............................................................................
J. Pemeriksaan fisikTTV:KU:
Kesadaran:
Suku:Persyarafan:TB/BB:
Pemeriksaan fisik head to toe
1. Kepalarambut: ......................
Mata: ......................
Hidung: ......................
Mulut: ......................
Telinga: ......................2. Leherdistensi vena jugularis:
.....................3. Dada dan aksila
Paru-paru: pergerakan dada
Penggunaan otot bantu pernapasan
Suara napas
JantungKecepatan denyut apikalIrama
Bunyi jantung
Nyeri dada
PayudaraKesan umum
Areola mamae
Papila mamaecolostrum4. AbdomenFundus uteri Tinggi Posisi
Kontraksi
Luka bekas operasi
Tanda infeksi
Kondisi vesika urinaria
5. Ano-genitalLochea Jumlah Warna
Konsistensi
Bau
Keadaan perinium
Utuh Episiotomi
Ruptur
REEDA sgu
KebersihanHemoroid :6. Ekstremits : Varises
Homans sign
Edema
IV. PEMERIKSAAN PENUNJANG
Lab: Darah
UrineBandar Lampung, .............................. 2007
Mahasiswa,
(.......................................)
Nim :
