Senin, 21 Januari 2013

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL KEPERAWATAN MATERNITAS


FORMAT PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL
KEPERAWATAN MATERNITAS

Nama Mahasiswa       :
NIM                             :
Tempat Praktek          :
Tanggal                       :  Pengkajian   :          
                                       Praktik          :
I.          IDENTITAS PASIEN
Nama                             : ......................................................................................
Umur                              : ......................................................................................
Status Perkawinan         : ......................................................................................
Agama                           : ......................................................................................
Suku                               : ......................................................................................
Pendidikan                     : ......................................................................................
Nama Suami                  : ......................................................................................
Umur Suami                  : ......................................................................................
Alamat                            : ......................................................................................
Pekerjaan                       : ......................................................................................
Diagnosa Medis             : ......................................................................................
Tanggal Masuk RS        : ......................................................................................
II.        KELUHAN UTAMA
....................................................................................................................................
III.       RIWAYAT PENYAKIT DAHULU
....................................................................................................................................
IV.      RIWAYAT PENYAKIT KELUARGA
....................................................................................................................................
V.        RIWAYAT GINEKOLOGI
....................................................................................................................................
VI.      RIWAYAT OBSTETRI
§  Menarche usia         : ......................................................................................
§  Siklus Menstruasi     : teratur/ tidak,............hari.
§  Karakteristik mens   : ......................................................................................
§  G.....P.....A.....
§  HPMT                                  : ......................................................................................
§  HPL                          : ......................................................................................
§  Keluhan selama kehamilan ini
Trimester I       : ..................................................................................................
Trimester II      : ..................................................................................................
Trimester III     : ..................................................................................................
VII.     KEBIASAAN YANG MERUGIKAN
Merokok             [     ]                 Obat-obat terlarang                 [      ]
Alkohol               [     ]                 Obat-obat yang dijual bebas   [      ]
VIII.    KELUARGA BERENCANA
....................................................................................................................................
IX.      KEBUTUHAN DASAR MANUSIA
§  NUTRISI
................................................................................................................................. 
ELIMINASI
.................................................................................................................................
§  ISTIRAHAT DAN TIDUR
.................................................................................................................................
§  SEKSUALITAS
.................................................................................................................................
§  PERSEPSI DAN KOGNITIF
.................................................................................................................................
 KONSEP DIRI
X.        PEMERIKSAAN FISIK
Keadaan Umum
§  Kesadaran    : ..................................................................................................
§  BB                : .......kg (kenaikan BB selama hamil : ......kg), TB :........m
§  Tanda Vital   : P        :.........x/menit              T          : .........°C
  R       : ........x/menit              BP       : .........mmHg
§  Kulit
Linea nigrae                [      ]                Cloasma          [      ]
Striae gravidarum       [      ]                Pucat               [      ]
Angioma                      [      ]                Eritema           [      ]
§  Kuku dan kaki                     
Oedema                      [      ]
Lainnya           : ..................................................................................................
§  Kepala
Sklera              : ..................................................................................................
Konjungtiva     : ..................................................................................................
Palpebra          : ..................................................................................................
Pembesaran limphe nodi        : ...........................................................................
Pembesaran kelenjar tiroid     : ...........................................................................
Telinga            : ..................................................................................................
THT                 : ..................................................................................................
§  Thoraks
Jantung           : ..................................................................................................
Paru                : ..................................................................................................
Payudara        : ..................................................................................................
§  Abdomen
.................................................................................................................................
§  Perineum
.................................................................................................................................
§  Muskuloskeletal
.................................................................................................................................
§  Syaraf
.................................................................................................................................
XI.      INFORMASI LAIN
....................................................................................................................................
XII.     ANALISA DATA
DATA
PROBLEM
ETIOLOGY







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