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LAPORAN PENGKAJIAN ANTENATAL CARE

Tanggal................................

Oleh :

_________________________

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FORMAT PENGKAJIAN ANTENATAL CARE

Pengkajian tanggal : ........................................Jam pengkajian : ........................................

I. IDENTITAS

Nama pasien : ..................................

Umur : ..................................

Suku/bangsa : ..................................

Agama : ..................................

Pendidikan : ..................................

Pekerjaan : ..................................

Alamat : ..................................

Nama suami : ..................................

Umur : ..................................

Suku/bangsa : ..................................

Agama : ..................................

Pendidikan : ..................................

Pekerjaan : ..................................

Alamat : ..................................

II. KELUHAN UTAMA / ALASAN KUNJUNGAN

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

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III. RIWAYAT KEIDANAN

!. R"#a$a% Pe&'a#"nanStatus perkawinan : kawin : ( ) a ( ) tidak

Jika kawin : berapa kali : !!!! lamana : !!!! usia : !!!!

(. R"#a$a% Ha")

"enar#$e umur : !!!!!!! ta$un

%aid : teratur : ( ) a ( ) tidak

siklus : !!!! $ari

&ismen're : ( ) a ( ) tidak

arna : ( ) mera$ tua ( ) mera$ segar

( ) mera$ ke$itaman ( ) #'klat

entuk $aid : ( ) #air/en#er ( ) bergumpal ( ) *lek

au $aid : ( ) anir ( ) busuk

+lu'r albus : ( ) a ( ) tidak

,apan : ( ) sebelum $aid ( ) sesuda$ $aid

-

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anakna : ( ) banak ( ) sedikit

ama : !!!!!!!!!!!!!!!

arna : !!!!!!!!!!!!!!!

au : !!!!!!!!!!!!!!!

*. R"#a$a% Keha+"lan, N"-a )an Ana' $ang Lal

I0. RIWAYAT KEHAMILAN SEKARANG

1. %P% ($amil berapa bulan)

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

-. anda0tanda ba$aa/penulit

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

. ,elu$an umum

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

2. 3bat0'batan/jamu ang dik'nsumsi: .......................................................................................

0. RIWAYAT KESEHATAN KELUARGA

1. ,eturunan kembar : ( ) a ( ) tidak

-. Penakit menular/keturunan :

( ) diabetes mellitus ( ) $epatitis ( ) PJ,

( ) ti*'id ( ) $ipertensi ( )

( ) lain0lain4 jelaskan .................................................................................................................

0I. RIWAYAT KESEHATAN YANG LALUPenakit menular/keturunan :

( ) diabetes mellitus ( ) $epatitis ( ) PJ,

( ) ti*'id ( ) $ipertensi ( )

( ) lain0lain4 jelaskan .......................................................................................................................

0II. PEMERIKSAAN

!. Kea)aan ++

( ) lema$ ( ) baik ( ) #ukup

(. Tan)a 1"%al

a. Su$u : !!!! 56 ( ) aksila ( ) 'ral ( ) rektal

b. Nadi : !!!! 7/menit ( ) teratur ( ) tidak teratur

#. Pernapasan : !!!! 7/menit

( ) teratur ( ) tidak teratur

( ) dalam ( ) dangkal

d. ekanan dara$ : !!!! mm%g

( ) berbaring ( ) duduk ( ) berdiri

e. erat badan : !!!! kg

*. inggi badan : !!!! #m

*. Ke2ala

a. aja$ : ( ) pu#at ( ) sian'sis

b. 8ambut : kebersi$an : !!!!!!!

r'nt'k : ( ) a ( ) tidak

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#. Pupil : ( ) is'k'r ( ) anis'k'r

( ) mi'sis ( ) midriasis

d. 8eaksi #a$aa : ( ) p'siti* ( ) negati*

e. ,'njungti9a : ( ) pu#at ( ) mera$ muda ( ) $iperemi

*. Sklera : ( ) puti$ ( ) ikterus ( ) perdara$an

g. "ulut dan gigi : ( ) karies ( ) st'matitis

( ) trismus ( ) perdara$an gusi

$. ida$ : ( ) bersi$ ( ) k't'r

i. elinga : ( ) serumen ( ) perdara$an

3. Lehe&

( ) pembesaran kelenjar tir'id

( ) pembesaran 9ena jugularis

( ) pembesaran kelenjar lim*e

( ) lain0lain4 jelaskan .................................................................................................................

4. Da)aa. arikan : ( ) ada ( ) tidak

b. entuk : ( ) simetris ( ) asimetris

#. Auskultasi paru : ( ) 9esikuler ( ) w$eeing ( ) r'nk$i

d. Auskultasi jantung : ( ) s1s-tunggal ( ) murmur ( ) gall'p

e. "amae : ( ) radang ( ) ada benj'lan ( ) tidak ada benj'lan

*. Puting susu : ( ) men'nj'l ( ) datar ( ) masuk

( ) bersi$ ( ) k't'r

( ) $iperpigmentasi are'la/papila

g. ,'l'strum : ( ) keluar ( ) belum

$. Pembesaran mamae : ( ) simetris ( ) asimetris

5. A6)7+en

a. ;nspeksi

inea : ( ) nigra ( ) alba

Striae : ( ) albi#ans ( ) li9idae

ekas luka 'perasi : ( ) ada ( ) tidak ada

b. Pembesaran : ( ) memanjang ( ) melintang

#. erli$at gerak anak : ( ) a ( ) tidak

d. Palpasi+U : ..........................................................................................................................

e. Perkusi : ( ) s'n'r ( ) redup ( ) timpani

*. Auskultasi

&JJ : ( ) negati* ( ) p'siti* !!!! 7/menit

( ) teratur ( ) tidak teratur

ising usus : ( ) negati* ( ) p'siti*

( ) menurun ( ) meningkat

8. Gen"%7&"na&"a

( ) ink'ntinensia ( ) retensi' urine ( ) disuria( ) p'liuria ( ) $ematuria

( ) terpasang kateter ( ) kandung kemi$ penu$

9. E'%&e+"%a a%a )an 6a#ah

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( ) edema ( ) 9arises ( ) plegia ( ) parese

8e*leks patela : .............................................................................................................................

entuk kaki : .............................................................................................................................

. Pe+e&"'aan 2enn;ang

a. ab'rat'rium : ..........................................................................................................

b. US< : ..........................................................................................................

#. 8'ntgen : ..........................................................................................................

d. erapi ang didapat : ..........................................................................................................

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