FORMAT PENGKAJIAN PADA IBU HAMIL

FORMAT PENGKAJIAN PADA IBU HAMILMAHASISWA PROGRAM D III KEPERAWATANSTIKES NANI HASANUDDIN MAKASSAR

No. Reg. Ibu

: ..............................Nama Mahasiswa :..................................Tgl. Kunjungan: ..............................Tgl. Pengkajian :..................................I. BIODATAA. IDENTITAS IBU / SUAMI : Nama

: ....................................../........................................... Umur

: ................tahun / .....................tahun Suku / bangsa: ...................................../ ........................................... Agama

: ...................................../ .......................................... Pend. Terakhir: ...................................../ ........................................... Pekerjaan: ...................................../ ................................. Lamanya menikah:................................... Alamat

: ...................................................................................B. DATA BIOLOGIS / FISIOLOGIS1. Keluhan utama (mual/muntah, pusing / sakit kepala, keluar darah, dll):.............................................................................................................................................................................................................................................................2. Riwayat keluhan :a. Mulai timbulnya .........................................................................................................b. Sifat keluhan (kwalitas / kwantitas) ......................................................................................................... ......................................................................................................................................................................................................................................c. Lokasi keluhan .......................................................................................d. Faktor pencetus ........................................................................................e. Keluhan lain ............................................................................................f. Pengaruh keluhan terhadap aktifitas / fungsi tubuh ..............................................................................................................................................................................................................................................................................................................................g. Usaha klien untuk mengatasi keluhan ......................................................................................................3. Riwayat kesehatan masa lalu :a. Penyakit yang pernah di derita .....................................................b. Riwayat opname ( kapan/alasan)....................................................c. Riwayat trauma ( kapan/alasan) ...................................................................................................... .............................................................................................................................................................................................................d. Riwayat operasi (kapan/alasan) ...................................................e. Riwayat tranfusi darah ( kapan, alasan, reaksi) :...................................................................................................................................................................................................................................................................................................................4. Riwayat kehamilan dan persalinan serta nifas yang lalu :NoKehamilanPersalinanAnakRiwayat Nifas

UmurKeadaanThnTempatPenolongJenisP/LLamanya menyusuiKeadaan skrg

5. Pola Reproduksi :a. Menarche umur:................................................................b. Siklus haid:................................................................c. Lamanya haid:................................................................d. Sifat darah:................................................................e. Dysmenorhoe:................................................................6. Riwayat pola kegiatan sehari-hari :a. Nutrisi :

Kebiasaan :

1) Pola makan .................................................................2) Frekuensi makanan sehari ..........................................3) Kebutuhan minuman / cairan .....................................Selama hamil :

1) Konsumsi perhari makanan sumber :

Karbohidrat ................................ Protein ........................................

Lemak .........................................

2) Nafsu makan .................................................................3) Masalah dengan gigi/mengunyah ................................4) Makanan yang disenangi .............................................5) Makanan yang di pantang ............................................6) Keluhan minum/cairan .................................................7) Perubahan lain .............................................................b. Eliminasi :Kebiasaan :

1) Frekuensi BAK: ....................................................2) Warna/bau khas : ...................................................3) Gangguan eliminasi BAK :....................................4) Frekuensi BAB :....................................................

5) Warna/konsistensi BAB :......................................

Selama hamil :

1) Poliuri :...................................................................2) Incontinensia uri :...................................................3) Dysuri :..................................................................

4) Hemoroid :.............................................................

5) Konstipasi :...........................................................

6) Perubahan lain ....................................................c. Kebutuhan kebersihan diri sendiri :Kebiasaan :

1) Kebersiahan rambut : ................................................

2) Kebersihan badan :....................................................

3) Kebersihan gigi/mulut :.............................................

4) Kebersihan genetalia dan anus :...............................5) Kebersihan kuku tangan/kaki :..................................6) Kebersihan pakaian :.................................................

Perubahan selama hamil ................................................................................................... ...................................................................................................d. Kebutuhan rekreasi / olah raga :Kebiasaan :

1) Jenis / frekuensi rekreasi : .........................................

2) Jenis / fekuensi olah raga :.........................................

3) Jenis rekreasi / olah raga :..........................................

Perubahan selama hamil : .................................................................................................... ....................................................................................................e. Kebutuhan istirahat /tidur :Kebiasaan :

1) Istirahat/tidur siang :..............................................

2) Istirahat/tidur malam :...........................................

3) Pekerjaan RT dilakukan : .....................................

4) Merawat anak dilakukan :....................................

Selama hamil :

1) Perubahan : ............................................................................................ ..............................................................................................2) Peranan keluarga dalam membantu ibu istirahat : ..............................................................................................................................................................................................

f. Kebutuhan seksual ( bila mungkin / perlu )1) Kebiasaan : .........................................................................2) Perubahan selama hamil : ..........................................................................................................................................................................................7. Pemerikasaan Fisika. Pemeriksaan fisik umum :1) Penampilan ibu : ......................................................

2) Kesadaran : ..............................................................

3) Tinggi/BB: ...................Cm / ....................Kg

4) Tanda Vital :

Tekanan darah : .......................mmHg Denyut nadi : .........................../menit Temperatur /suhu : ...........................oC

Respirasi : ................................/menit

5) Inspeksi kepala dan rambut : Keadaan rambut : .................................................

Kebersihan rambut : .............................................

6) Inspeksi wajah/muka : Edema wajah/muka : ............................................

Topeng kehamilan : .............................................

Ekspresi wajah : .................................................

7) Mata :

Kebersihan : ........................................................

Konjungtiva : ......................................................

Sklera : ..............................................................

Kelopak mata : ...................................................

8) Inspeksi hidung :

Kesimetrisan : ..................................................... Sekret hidung : .................................................... Epistaksis : .........................................................

9) Inspeksi gigi dan hidung : Kebersihan gigi / mulut : .......................................... Keadaan gigi : ........................................................... Keadaan gusi : ........................................................... Keadaan lidah : .......................................................... Keadaan mukosa bibir : ............................................

Caries / protese : ........................................................10) Inspeksi telinga : Kebersihan telinga : ......................................................... Sekret telinga :..................................................................

Keadaan telinga luar : .....................................................

11) Inspeksi / palpasi leher : Pembesaran kelenjar gondok : ....................................... Pembesaran vena jugularis : ............................................

Pembesaran arteri karotis : ..............................................

12) Inspeksi / palpasi dan auskultasi dada /perut :a. Payudara :

Kesimetrisan : ....................................

Keadaan puting : ................................

Keadaan areola : ................................

Kolostrum : .......................................

b. Jantung Bunyi jantung : .......................................

Bunyi tambahan : ...............................

c. Paru Bunyi pernafasan : .............................

Bunyi tambahan : ..............................

d. Abdomen

Pembesaran : ..........................................................

Bentuk : .................................................................

Striae : ...................................................................

Linea : ...................................................................

Tanda hidramnion : ...............................................

Tampak gerakan janin : ........................................

Peristaltik usus : ..................................................

13) Inspeksi genetalia (vulva/anus)a. Kebersihan : ................................................................b. Tanda chadwick : ........................................................

c. Varises : .......................................................................

d. Flour albus : ................................................................

e. Kondilomata : ................................................................f. Pembesaran kel. lipat paha : ........................................14) Inspeksi dan palpasi tungkai bawah :a. Kesimetrisan : .............................................................

b. Edema pretibial : ........................................................

c. Varises : .....................................................................

b. Pemeriksaan Obstetri1. Palpasi ( Leopold)a. Tinggi Fundus Uteri : ...............................................b. Posisi janin : .............................................................

c. Presentasi janin : ......................................................

d. Masuknya presentasi : ............................................

2. Auskultasi DJJa. Irama/regularitas : ..................................................b. Frekuensi :.........................................kali / menit

c. Gerakan usus : .......................................................

3. Pemeriksaan panggul (tgl pengukuran)a. Distansia spinarum : ...............cmb. Distansia kristarum : ...............cm

c. Konjugata eksterna : ................cm

d. Distansia tuberum : ..................cm

e. Ukuran lingkar perut : ..........cm4. Pemerikasaan laboratorium (hasil tgl)a. Urine :

Albumin : ................................

b. Darah :

HB

Golongan darah

c. Keluarga Berencana Apakah ibu mengerti tentang KB : .............................. Apakah ibu setuju dengan KB : ................................... Apakah ibu pernah menjadi akseptor : ....................... Apakah metode kontrasepsi yang digunakan : ........... Apakah pernah drop out /berhenti: ...................alasannya...................... ........................d. Data Psikologis /sosiologisa. Reaksi emosional terhadap kehamilan Rencana untuk hamil : ........................................... Respon ibu : .......................................................... Respon suami : ...................................................... Respon Keluarga :..................................................b. Peranan ibu dalam keluarga

pengambilan keputusan : ...................................... konsultasi kesehatan : .......................................... Penentuan diet dan makan pantang : .................... Lain-lain : ..............................................................e. Data Spritual1. Hubungan keyakinan ibu dengan kehamilannya :.................... ......................................................2. Usaha ibu untuk berdoa terhadap kesehatannya :..................... .......................................................3. Pantangan menurut keyakinan ibu selama kehamilan :............ ...............................................................4. Keharusan menurut keyakinan ibu selam kehamilan :.............. .................................................................f. Data tambahan lain :

1. Keluarga klien : ........................................................................

2. Tim kesehatan yang terlibat :.................................................... ....................................................................................Makassar, ....... .....................2015Mahasiswa yang bersangkutan,

(.............................................)

FORMAT PENGKAJIAN PADA IBU INPARTU MAHASISWA PROGRAM D III KEPERAWATAN STIKES NANI HASANUDDIN MAKASSAR

I. BIODATA

a. Identitas istri / ibu : Nama

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

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

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

: ..................................................................... Pendidikan terakhir: ........................................................................ Pekerjaan

: ........................................................... Penghasilan / bln

: ................................................................... Status perkawinan : .................................................................. Lamanya

: ...................................................................... Perkawinan yang ke: ................................................................. Alamat

: ................................................................... Tanggal kunjungan: ...................................................................b. Identitas Suami : Nama

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

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

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

: .................................................................... Pendidikan terakhir: ................................................................... Pekerjaan

: ............................................................... Penghasilan / bln: ................................................................. Status perkawinan : .................................................................. Lamanya

: ................................................................... Perkawinan yang ke: ...................................................................

Alamat

: ..................................................................II. DATA BIOLOGIS / FISIOLOGISa. Keluhan utama : .......................................................................................b. Riwayat keluhan utama : ........................................................................c. Riwayat kehamilan sekarang :

G : ..................... P : ...................... A : .....................................

tafsiran persalinan ................................................................... Jam berapa uterus mulai berkontraksi : ................................. Kontraksi His ............................................... Interval His .................................................d. Riwayat kehamilan dan persalinan serta nifas yang laluNoKehamilanPersalinanAnakRiwayat Nifas

UmurKeadaanThnTempatPenolongJenisP/LLamanya menyusuiKeadaan skrg

e. Pola Reproduksi : Menarche umur ...................................... Sikluis haid ............................................ teratur /tidak .........................................

Lamanya haid ......................................... Sifat darah ............................................. Dysmenorhoe .......................................f. Riwayat kesehatan

Riwayat penyakit yang pernah dialami / terutama yang berpengaruh terhadap kehamilan .......................................................................... Riwayat operasi yang pernah dialami ............................................. Riwayat keluhan ;

a. Penyakit : TBC, hepatitis, kejiwaan, malaria, DM atau penyalit lainnya ..................................................................................b. Kehamilan kembar ...............................................................g. Pola kegiatan sehari-hari

1. Nutrisi : Jenis makanan ............................................................................ Frekuensi makanan sehari ......................................................... Nafsu makan ............................................................................. Makanan pantang .................................................................... Makanan kesukaan .................................................................. Banyaknya minum sehari..........................................................2. Eliminasi :b. Buang air besar : Frekuensi...............................................

Warna ...................................................

Konsistensi .........................................

c. Buang air kecil :

Frekuensi ............................................ Warna .................................................

Jumlahnya ..........................................

3. Istirahat (tidur) : Tidur waktu malam berapa jam (dari pukul ............s/d.............)

Tidur waktu siang berapa jam ( dari pukul ............s/d .............)

4. Kebersihan diri :

Penampilan umum ..................................................................... Mandi / hari ............................................................................... Sikat gigi / hari .......................................................................... Cuci rambut / minggu ............................................................... Ganti pakaian dalam dan luar sehari .........................................5. Rekreasi / olah raga atau hobby ;............................................................................ :.............................................................................................................6. Ketergantungan :

Obat .................................................................... Rokok .................................................................

Minuman keras ...................................................

7. Hubungan seksual, keluhan :.............................................................8. Riwayat Keluarga Berencana : .......................................................... Mengerti tentang KB .................................................................. Setuju tentang KB ....................................................................... Pernah menjadi akseptor ........................................................... Drop out, alasannya ...................................................................h. Pemeriksaan fisik

a. Tanda-tanda vital : Tekanan darah ................................mmHg Suhu .............................oC

Pernafasan ................../menit

Nadi ............................/ menit

b. Berat badan ......................Tinggi badan ..............................

c. Cara berjalan ........................................................................d. Kesadaran umum .................................................................e. Inspeksi :1. Kepala Rambut ...................................................................2. Muka

Pucat

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

Kloasma gravidarum : .................................................

Sianosis

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

Udema

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

3. Mata

Kelopak mata: ...................................................... Skelera mata: .....................................................

Konjungtiva: .....................................................

4. Mulut dan gigi

Berbau

: ................................. kebersihan: ................................

Jumlah gigi: ................................

Caries

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

Stomatitis

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

5. Leher

Pembesaran kelenjar : ................................................6. Buah dada Bentuknya : ................................... ...................... kebersihan : ......................................................... Keadaan puting susu : ......................................................... Pengeluaran kolestrum: .......................................................7. Perut

Bentuknya

: ................................................................ linea/strias

: ................................................................. Bakas luka operasi : .............................................................

8. Vulva

Udema

: ....................................................... tanda chadwick

: ...................................................... Pengeluaran darah lendir dari vagina: ......................... Kebersihan

: .......................................................9. Tungkai

Varises: ................................................................................. Udema: .................................................................................. simetris : .................................................................................f. Pemeriksaan panggul luar dan perut1. Lingkar panggul : ......................................................................2. Lingkar perut: .....................................................................3. Distensia cristarum: .....................................................................4. Boudologue

: .....................................................................g. Palpasi :

1. Tinggi Fundus Uteri: ..........................................................

2. Punggung janin : ...................................................................3. Bagian terdepan: ...................................................................4. Turunnya bagian terdepan : .......................................................h. Auskultasi :1. Bunyi jantung janin : ..................................................................2. Frekuensi

: ....................................................................3. Lokasi paling jelas: ....................................................................4. Gerak janin

: ....................................................................5. Bunyi jantung ibu: ....................................................................i. Perkusi :

Refleks patella : Kanan .....................kiri ................................j. Pemeriksaan laboratorium

1. Urine :

Albumin

:.......................................................................2. Darah :

Golongan darah:...................................................................... HB

:......................................................................k. Pemeriksaan rontgen : ....................................................................III. RIWAYAT PERSALINAN SEKARANGa. Kala I

1. Lamanya

: .................jam ...................menit

2. Tanda Vital

Tekanan darah

: ............................ Nadi

: ............................. Pernafasan

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

3. Palpasi menurut Leopold :

TFU

: ..................................................... Punggung janin

: ..................................................... Bagian yang terdepan

: ........................................... Turunnya bagian terendah: ...........................................4. His (kontraksi uteri )

Tanggal

: ......................jam .................menit Frekuensi

: ................................. lamanya

: ................................ Intensitas (kekuatannya: .................................5. Vaginal toucher :

Dilakukan oleh

: ................................................. Indikasi

: ................................................. Tanggal

: ................................................. Pembukaan

: ................................................. Serviks

: ................................................. Ketuban

: ................................................. Bagian paling bawah: ................................................. Kesan panggul

: .................................................b. Kala II

1. Lamanya

: .................jam ...................menit2. His intensitasnya

: ..........................................................3. Denyut Jantung Janin (DJJ): frekuensi ...........jumlahnya .............. Bagian paling depan: .....................presentasio .................. Pelepasan lendir

: ........................................................... Ketuban pecah

: ........................................................Warnanya

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

baunya

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

jumlahnya

: ............................................................ Keadaan His

: ........................................................... keadaan perineum

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

Ibu mulai mengedan: ........................................................... caranya mengedan

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

Bayi lahir tanggal

: ................................jam .................... Jenis persalinan

: .......................................................... Perdarahan

: ..........................................................4. Keadaan bayi:

Apgar skor

: 1 menit setelah lahir : ........................... Apgar skor

: 5 menit setelah lahir :............................ Berat badan lahir

: ..........................gram panjang badan

:.... ......................cm Cacat bawaan

: ............................................................ Setelah 5 menit lahir apakah ada mekonium : ..................................c. Kala III

1. Lamanya

: .....................................................menit

2. TFU setelah bayi lahir

: .............................................................3. Katerisasi urine

: ..............................................................4. Lahirnya placenta

: ..............................................................5. Pemeriksaan placenta

: Beratnya

: .............................................................. Tali pusat

:

Panjang

: ....................cm

Keadaan

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

Tanda VitalIbu

: Tekanan darah

: .......................mmHg

Nadi

: ......................./ menit

Pernafasan

: ....................../ menit

Suhu

: .....................oC

Perdarahan

: .............................................................IV. DATA PSIKOLOGIS1. Pola interaksi ..........................................................................................2. Reaksi dan persepsi terhadap kehamilan .............................................. Direncanakan ................................................................................... Apakah klien cemas dengan persalinannya ........................................ Jenis kelamin yang diharapkan ............................................................ Bantuan pelayanan yang diharapkan ................................................... Kebutuhan kesehatan yang diharapakan .............................................. Perawatan payudara agar ASI cukup untuk kebutuhan bayi

Bimbingan tentang perawatan bayi

Pelayanan yang telah diberikan :............................................................................. ..................................................................................................................................................................................................................................................................................................

V. DATA SOSIAL

1. Bagaimana hubungan terhadap keluarga .............................................2. Bagaimana hubungan terhadap tetangga / masyararat ........................3. Bagaiman hubungan dengan pasien yang di rawat di rumah sakit ........4. Siapa yang paling terpenting bagi pasien ..............................................5. Siapa yang menanggung perawatan .....................................................VI. DATA SPRITUAL

1. Keyakinan kepada Tuhan YME

2. Ketaatan dalam melaksanakan ibadah sekarang

Makassar, ............................2014Mahasiswa yang bersangkutan,

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