Post on 22-Jan-2016
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PENGKAJIAN PRENATAL
Nama Mahasiswa : …………………………….. Tgl. Pengkajian :……………………..
Stambuk : ……………………………... Ruangan/RS : ........................
DATA UMUM KLIEN
1. Inisial Klien :
2. Usia :
3. Status perkawinan :
4. Pekerjaan :
5. Pendidikan :
Riwayat Kehamilan dan Persalinan yang lalu
No. Tahun Jenis
persalinan
Penolong Jenis Kelamin Keadaan Bayi
waktu lahir
Masalah
kehanmila
n
1.
2.
3.
4.
5.
Pengalaman menyusui : ya/tidak Berapa lama :
Riwayat Ginekologi
1. Masalah ginekologi :
2. Riwayat KB
:
Riwayat Kehamilan saat ini
HPHT :............................ Taksiran partus :..............................
BB sebelum hamil :............................ TD sebelum hamil :........................................
TD BB/TD TFU Letak/presentasi janin DJJ Usia Gestasi Keluhan Data lain
DATA UMUM KESEHATAN SAAT INI
Status obstetrik : G... P... A... H... Minggu
Keadaan umum :..................... Kesadaran :.......................... ..BB/TB :.............................. Kg/cm
Tanda Vital
Tekanan Darah:.............mm Hg; Nadi :................x/mnt.
Suhu:............... C Pernapasan : ...............x/mnt
Kepala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah Khusus : ..........................................................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI :
Masalah Khusus : ............................................................................................
Abdomen
Uterus
TFU :....................cm kontraksi : ya/tidak
Leopold I : kepala/bokong/kosong
Leopold II : kanan : punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/bokong/kepala
Leopold III : kepala/bokong/kosong
Leopold IV : bagian masuk PAP
Pigmentasi
Linea nigra :
Striae
Fungsi pencernaan :
Masalah Khusus : ...............................................................................................
Perineum dan Genital
Vagina : vrises; ya/tidak
Kebersihan :…….
Keputihan :
Jenis/warna :.......................Konsistensi : ....................... Bau : .......................
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :..................................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Refleks patela : +/- jika ada : +1/+2/+3
Masalah khusus : ………………………………………………………
Eliminasi
Urin : kebiasaan BAK……………………………………………
Fekal : kebiasaan BAB.............................................................
Masalah Khusus :.....................................................................................
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ..................................................................................
Nutrisi dan Cairan
Asupan nutrisi : ....................................nafsu makan : baik/kurang/tidak ada
Asupan cairan : ...................................cukup/kurang
Masalah khusus : ...........................................................................................
Keadaan Mental
Adaptasi psikologis : ......................................................................................
Penerimaan terhadap kehamilan :..................................................................
Masalah khusus : ..........................................................................................
Pola hidup yang meningkatkan risiko
kehamilan : .......................................................................................................................................
.......................................................................................................................................
Persiapan Persalinan
□ Senam hamil
□ Rencana tempat melahirkan
□ Perlengkapan kebutuhan bayi dan ibu
□ Kesiapan mental ibu dan keluarga
□ Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri,
proses persalinan
□ Perawatan payudara
Obat-obatan yang dikonsumsi saat ini :
Hasil pemeriksaan penunjang :
RANGKUMAN HASIL PENGKAJIAN
Masalah :
.........................................................................................................................
........................................................................................................................
........................................................................................................................
Perencanaan Kunjungan rumah :
PENGKAJIAN INTRANATAL
Nama Mahasiswa : ....................................... Tanggal Pengkajian : ................................................
NIM : .............................. RS/Ruangan : ..................................................
I. DATA UMUM
Inisial klien : ................ (.....th) Nama Suami : .............................(......th)
Pekerjaan : ............................... Pekerjaan : .............................................
Pendidikan Terakhir : .............. Pendidikan terakhir :.............................
Agama : ................................... Agama : .............................................
Suku bangsa :......................
Status perkawinan : ......................................................
Alamat : .........................................................................................................
II. DATA UMUM KESEHATAN
TB/BB : ................cm/.................kg
BB sebelum hamil : .....................kg
Masalah kesehatan khusus : ...........................................................................
Obat-obatan : .................................................................................................
Alergi (obat/makanan/bahan tertentu) : .........................................................
Diet khusus : ..................................................................................................
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain-lain : .......................................................................................................
Frekuensi BAB/BAK :...................................................................................
Masalah BAB/BAK : ..................................................................................................
Kebiasaan waktu tidur : ..............................................................................................
III. DATA UMUM KEBIDANAN
Kehamilan sekarang direncanakan (ya/tidak)*
Status Obstetri : G ...........P.............A ............H ..............(minggu)
HPHT : .................................Taksiran partus : ................................................
Jumlah anak di rumah : ..............................................
No Jenis
kelamin
Cara lahir BB
Lahir
Keadaan saat ini Umur
Mengikuti kelas prenatal (ya/tidak) : ..............
Jumlah kunjungan ANC pada kehamilan ini : .......................................
Masalah kehamilan yang lalu : ....................................................................................
Masalah kehamilan sekarang : .....................................................................................
Rencana KB : .............................
Makanan bayi sebelumnya : ASI/PASI/lainnya*
Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi,/pernafasan/manfaat ASI/cara memberi minum botol/senam nifas/metode
KB/perawatan perineum/perawatan payudara/lain-lain,
jelaskan ...............................................................................................................................
.........
Setelah bayi lahir, siapa yang diharapkan membantu : .................................................
Masalah dalam persalinan yang lalu : ...........................................................................
IV. RIWAYAT PERSALINAN SEKARANG
Mulai persalinan (kontraksi): tanggal/jam : ............................
Pengeluaran pervaginam (tanggal/jam) : ...............................
Keadaan kontraksi (frekuensi dalam 10 menit, lamanya,
kekuatannya) : .....................................................................................................................
................................................................................................................................
Denyut jantung janin : Frekuensi ...................................
Kualitas : ...................................
Irama : .......................................
Pemeriksaan fisik :
Kenaikan BB selama hamil : .....................kg
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Kepala dan leher :..................................................................................(normal/tidak)
Jantung : ......................................................................................................................
Paru-paru : ...................................................................................................................
Payudara : ....................................................................................................................
Abdomen : (secara umum dan pemeriksaan obstetrik) : ............................................
.....................................................................................................................................
Ekstremitas : edema/tidak ..........................................................................................
Refleks : ......................................................................................................................
Pemeriksaan dalam pertama : (jam) .......................oleh : ............................................
Hasil : ..................................... .....................................................................................
Ketuban : (utuh/pecah), jika sudah pecah : tgl/jam :...................................................
warna......................................................
Laboratorium : ..............................................................................................................
..............................................................................................................
..............................................................................................................
V. DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : ............................................................................
Perasaan klien terhadap kehamilan sekarang : ...........................................................
Perasaan suami terhadap kehamilan sekarang : .........................................................
Jelaskan respon sibling terhadap kehamilan sekarang : .............................................
LAPORAN PERSALINAN
I. Pengkajian awal
Tanggal : .........................Jam : ............................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Pemeriksaan palpasi abdomen
Leopold I : ..............................................................................
Leopold II : . ..............................................................................
Leopold III : ..............................................................................
Leopold IV : ..............................................................................
Hasil pemeriksaan dalam : ...............................................................................
Pemeriksaan perineum : .........................................................................................
Dilakukan klisma (ya/tidak) : .............
Pengeluaran pervaginam : ................................................................
Perdarahan pervaginam (ya/tidak) :.................
Kontraksi uterus (frekuensi, lamanya, kekuatan) : ................................................
DJJ : (frekuensi/kualitas)................................./.....................................................
Status janin : (hidup/tidak,jumlah,presentasi) : .....................................................
...............................................................................................................................
II. Kala persalinan
Kala I
Mulai persalinan : (tanggal/jam)............................................................................
Tanda dan gejala : .................................................................................................
Lama Kala I : (jam/menit/detik)............................................................................
Keadaan psikososial : ...........................................................................................
Kebutuhan khusus klien : .....................................................................................
Tindakan : ............................................................................................................
Pengobatan : .........................................................................................................
Observasi kemajuan persalinan :
Tanggal/jamKontraksi
uterusDJJ Keterangan
Kala II
Kala II dimulai : (Tgl/jam) : ...................................................................................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Lama kala II : (jam/menit/detik) ...................................................................................
Keadaan psikososial : ...................................................................................................
Kebutuhan khusus klien : .............................................................................................
Tindakan : .....................................................................................................................
Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur : ................................
Bonding ibu dan bayi :.......................
TTV bayi : TD......................mmHg,N...............x/mnt S...............oC P..............x/mnt
Pengobatan : .................................................................................................................
Catatan kelahiran :
Bayi lahir jam : .......................................
Jenis kelamin : ........................................
Nilai APGAR menit I................................menit V...........................
BB/PB/lingkar kepala : .........................gram.........................cm....................cm
Karakteristik khusus bayi : ..........................................................................................
Kaput suksadaneum/cephal hematoma : ......................................................................
Anus : berlubang/tertutup*
Perawatan tali pusat :..............................................................
Perawatan mata : ...................................................................
Kala III
Mulai jam : .................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Tanda dan gejala :...........................................................................................................
Plasenta lahir jam : ........................................................................................................
Cara lahir plasenta :.........................................................................
Karakteristik plasenta .....................................................................
Diameter : ..........cm
Ketebalan : .............cm
Panjang tali pusat : ..........................................................................
Jumlah pembuluh darah :.........................arteri .......................vena
Insersio tali pusat : ..........................................................................
Kelainan : ........................................................................................
Perdarahan : .........................ml
Karakteristik perdarahan : ...............................................................
Keadaan psikososial : ......................................................................
Kebutuhan khusus : .........................................................................
Tindakan : .......................................................................................
Pengobatan : ....................................................................................
Kala IV
Mulai jam : ................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Kontraksi uterus : ..........................................................................................................
Perdarahan :......................ml
Karakteristik : ...............................................................................................................
Tindakan : ....................................................................................................................
FORMAT RESUME BAYI BARU LAHIR
Tanggal lahir bayi : ....................................... Tanggal pengkajian : ...............................
Proses Kelahiran bayi :
Perawatan bayi yang dilakukan :
PENGKAJIAN POST PARTUM
Nama Mahasiswa :................................................... Tanggal Pengkajian :.............................
Stambuk : .................................................. Ruangan/RS : .............................
DATA UMUM KLIEN
1. Inisial klien Inisial Suami
2. Usia Usia
3. Status perkawinan Status perkawinan
4. Pekerjaan Pekerjaan
5. Pendidikan terakhir Pendidikan terakhir
Riwayat Kehamilan dan Persalinan Yang Lalu
No. Tahun Tipe
Persalinan
Penolong Jenis
kelamin
BB
lahir
Keadaan bayi
waktu lahir
Masalah
kehamilan
Pengalaman menyusui : ya/tidak berapa lama :
Riwayat Kehamilan saat ini
1. Berapa kali periksa kehamilan
2. Masalah kehamilan
Riwayat Persalinan
1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV,EF)
SC ......................... Tgl/jam :...............
2. Jenis kelamin bayi : L/P, BB/PB :........gram/......cm,
3. Perdarahan :...........................cc
4. Masalah dalam persalinan ..................................................
Riwayat Ginekologi
1. Masalah ginekologi
2. Riwayat KB
DATA UMUM KESEHATAN SAAT INI
Status obstetrik : G... P... A... H... Bayi Rawat Gabung : Ya/tidak
Jika tidak, alasan : ..........................................
Keadaan umum :..................... Kesadaran :.......................... ..BB/TB :.............Kg/cm
Tanda Vital
Tekanan Darah:.............mmHg; Nadi:....................Suhu:............... C
Pernapasan : ...............x/mnt
Kepala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah Khusus : .....................................................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI :
Masalah Khusus : .....................................................................................
Abdomen
Involusi Uterus
Fundus Uteri :....................kontraksi : .................Posisi :......................
Kandung kemih
Diastasis rektus abdominis ......................x......................cm
Fungsi pencernaan :
Masalah Khusus : .................................................................................
Perineum dan Genital
Vagina : integritas kulit.....edema.....memar.....hematom.........
Perineum : Utuh/episiotomi/ruptur Tanda REEDA
R : Kemerahan : ya/tidak
E : Edema : ya/tidak
E : Ekimosis : ya/tidak
D : Dischargeserum/pus/darah/tidak ada
A : Approximate : baik/tidak
Kebersihan :…….
Lokia :
Jumlah : ............Jenis/warna :..............Konsistensi : .............Bau : ............
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :...............................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Tanda Homan : +/-
Masalah khusus : ……………………………………………..............
Eliminasi
Urin : kebiasaan BAK……………………………………………
BAK saat ini......................................nyeri/tidak
Fekal : kebiasaan BAB.............................................................
BAB saat ini.....................................konstipasi/tidak :
Masalah Khusus :...................................................................................
Istirahat dan Kenyamanan
Pola tidur : kebiasaan tidur, lama...jam, frekuensi............
Pola tidur saat ini.................
Keluhan ketidaknyamanan : ya/tidak, lokasi................
Sifat....................intensitas...........................
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ........................................................................
Nutrisi dan Cairan
Asupan nutrisi : ....................nafsu makan : baik/kurang/tidak ada
Asupan cairan : ...................................cukup/kurang
Masalah khusus : ............................................................................
Keadaan Mental
Adaptasi psikologis : .....................................................................
Penerimaan terhadap bayi :...........................................................
Masalah khusus : ...........................................................................
Kemampuan menyusui: .................................................................................
Obat-obatan yang dikonsumsi saat ini :
Hasil pemeriksaan penunjang :
RANGKUMAN HASIL PENGKAJIAN
Masalah :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Perencanaan Pulang :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
PENGKAJIAN KELUARGA BERENCANA
Nama mahasiswa : ……………………… Tanggal pengkajian :………………………
NIM : ……………………………………… Ruangan/RS : ………………………………
I. Data umum klien :
Initial klien : ......................................................................................................
Usia : ...............................................................................................................
Status perkawinan : ........................................................................................
Pekerjaan : .....................................................................................................
Agama : ..........................................................................................................
Suku bangsa : .................................................................................................
II. Data umum kesehatan saat ini
TB/BB : ................................................cm/ .................................................kg
Keadaan umum : ...........................................................................................
Tanda-tanda vital : TD : ………mmHg, N : ………x/mnt
P : ............x/mnt, S : ..................oC
Kepala dan rambut :
Bentuk kepala : ………………………………………………………………….
Keadaan rambut : ……………………………………………………………….
Kebersihan rambut : ……………………………………………………………
Wajah/muka : ………………………………………………………………………
.....................................................................................................................
Mata :
Konjungtiva : ……………………………………………………………………
Sclera : …………………………………………………………………………..
Gangguan penglihatan : ……………………………………………………….
Hidung : …………………………………………………………………………….
Mulut : ……………………………………………………………………………..
Telinga : ……………………………………………………………………………
Leher : ………………………………………………………………………………
Dada :Payudara : ……………………………………….......................................
Abdomen : …………………………………………………………………………..
Genitalia : ……………………………………………………………………………
Tungkai bawah : …………………………………………………………………….
III. Data umum kebidanan
Status obstektrik : G ............P.............A ...........
Jumlah anak di rumah :
No Umur Jenis
kelamin
Cara
persalinanBB lahir
Keadaan
sekarang
1
2
3
4
5
Alasan datang ke klinik : ……………………………....................................................
Lama perkawinan : …………………………………………….....................................
Masalah untuk hamil : …………………………………………........................................
Masalah selama kehamilan : ………………………………...........................................
Masalah setelah melahirkan : ……………………………………..................................
Penggunaan alat kontrasepsi sebelumnya : ………………...........................................
Cara KB yang di minati : ..........................………………..............................................
Riwayat sosial : ............................................................................................................
PENGKAJIAN GANGGUAN SISTEM REPRODUKSI (GSR)
Nama mahasiswa : ……………………… Tanggal pengkajian :………………………
NIM : ……………………………………… Ruangan/RS : ………………………………
I. Data umum klien
No. Reg : ......................................................................................................
Initial : ...........................................................................................................
Alamat : ......................................................................................................
Tgl masuk RS : .............................................................................................
Tgl pengkajian : ............................................................................................
Tindakan medis : ..........................................................................................
II. Masalah utama
Keluhan utama :
Riwayat keluhan utama
mulai timbulnya :
sifat keluhan :
lokasi keluhan
faktor pencetus :
keluhan lain :
pengaruh keluhan terhadap aktivitas/fungsi tubuh :
usaha klien untuk mengatasinya :
III. Pengkajian
Seksualitas
Subyektif :
Usia menarche : ..........tahun
Siklus haid : .................hari
Durasi haid : ................hari
Dismenorea Polimenorea Oligomenorea
Menometroragie Amenorea
Rabas pervagina : warna : ............................................
Jumlah : .........................................
Berapa lama : ................................
Metode kontrasepsi terakhir : .......................................
Status obstetri : G : ......................... P : .......................A : ........................
Riwayat persalinan :
Term penuh :................. Prematur : ................
Multiple : .......................
Riwayat persalinan terakhir :
Tahun :.......................... tempat : ...................
Lama gestasi : .............. lama persalinan : ................................
Jenis persalinan : ......................................................................
Berat badan bayi : ..............gr
Komplikasi maternal/bayi : ..........................................................
Obyektif :
PAP smear terakhir (tgl dan hasil) : ............................................................
Tes serologi (tgl dan hasil) : ......................................................................
Makanan dan Cairan
Subyektif :
Masukan oral 4 jam terakhir : .....................................................................
Mual /muntah Hilang nafsu makan Masalah mengunyah
Pola makan :
Frekuensi : ...........x/hari
Konsumsi cairan : ....................../hari
Obyektif :
BB : ................kg
TB : ................cm
Turgor kulit : .................................................................................................
Membran mukosa mulut : .............................................
Nyeri
Subyektif :
Lokasi : .............................................. .............................
Intensitas (skala 0-10): ...................................................
Frekuensi : .......................................................................
Durasi : ............................................................................
Faktor pencetus : .............................................................
Cara mengatasi : ..........................................................................................
Faktor yang berhubungan : ..........................................................................
Objektif :
Wajah meringis
Melindungi area yang sakit
Fokus menyempit
Pernafasan
Subyektif :
Dispnoe Batuk/sputum Riwayat Bronkhitis
Asma Tuberkulosis Emfisema
Pneumonia berulang Perokok, lamanya : ..........tahun
Penggunaan alat bantu pernafasan (O2) : ........L/menit
Obyektif :
Frekuensi : ...............x/menit
Irama : Eupnoe Tachipnoe Bradipnoe
Apnoe Hiperventilasi Cheynestokes
Kusmaul Biots
Bunyi nafas : Bronchovesikuler Vesikuler Bronchial
Karakteristik sputum :
Hasil rontgen :