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

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III.       RIWAYAT PENYAKIT DAHULU

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IV.      RIWAYAT PENYAKIT KELUARGA

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V.        RIWAYAT GINEKOLOGI

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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

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IX.      KEBUTUHAN DASAR MANUSIA

§  NUTRISI

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ELIMINASI

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§  ISTIRAHAT DAN TIDUR

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§  SEKSUALITAS

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§  PERSEPSI DAN KOGNITIF

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 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

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§  Perineum

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§  Muskuloskeletal

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§  Syaraf

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XI.      INFORMASI LAIN

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XII.     ANALISA DATA

DATA	PROBLEM	ETIOLOGY