FORMAT ASKEP IBU HAMIL (ANC)

PENGKAJIAN

I. IDENTITAS

Nama ibu : Nama suami :

Umur : Umur :

Pendidikan : Pendidikan :

Agama : Agama :

Pekerjaan : Pekerjaan :

Status perkawinan :

Alamat :

Tanggal pengkajian :

Diagnosa medis :

2. DATA SUBJEKTIF

a. keluhan utama..............................................................................................................................................................................................................................................................................

b. riwayat Kesehatan Sekarang

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

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

c. Riwayat Kehamilan Sekarang

ANC(Ante Natal Care):.........................teratur/tidak.................................................

Diperiksa : ..............................................................................................

Imunisasi :.............................................................................................

Usia kehamilan : .............................................................................................

d. Riwayat Menstruasi

Menarche ....................siklus......................lamanya..........teratur/tidak...........

Jumlah :......................Warna:..................dismenorhe:...................................

HPHT :......................taksiran persalinan persalinan..............

e. Riwayat obstetri

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

ANAK KE

JENKEL UMUR RIWAYAT PERSALINAN

LANIR USIA HAMIL

PENOLONG PENYULIT BBL KET

f. Riwayat Kesehatan / Penyakit Yang lalu :

penyakitalergimerokok dan obat-obatan

g. Riwayat penyakit Keluarga

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

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

h. Keadaan Psikososial

Perubahan kehamilan terhadap kehidupan sehari-hari............................................................................................................................

Harapan yang didinginkan selama kehamilan...........................................................................................................................

Ibu tinggal serumah dengan siapa...........................................................................................................................

Yang menemani ibu ke klinik...........................................................................................................................

Rencana melahirkan

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

Rencana menyusui...........................................................................................................................

i. Seksual

dampak kehamilan terhadap perubahan pola seksual ..........................................................................................................................................

j. riwayat keluarga Berencana

Jenis kontrasepsi yang pernah digunakan .................................................................................................................................

Masalah-masalah yang dailami selama kehamilan ..................................................................................................................................

Jumlah anak yang direncanakan ..................................................................................................................................

k. pola kehidupan sehari-hari

Pola makan Diet kebiasaan (jenis)............................................................................................................................

Perubahan dalam pola makan............................................................................................................................

Pandangan selama kehamilan terhadap makanan............................................................................................................................

Masalah mengunyah/menelan............................................................................................................................

Kenyamanan, aktivitas dan istirahat Kenyamanan selama kehamilan dan cara mengatasinya............................................................................................................................

Aktivitas/hobi kebiasaan............................................................................................................................

Aktivitas kesenangan............................................................................................................................ Pembatasan selama kehamilan kondisi

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

Perubahan istirahat, tidur,dan cara mengatasinya........................................................................................................................... Jumlah jam istirahat/ tidur perhari

............................................................................................................................ Pola eleminasi

Buang Air Besar

Dampak kehamilan terhadap pola eleminasi Frekuensi BAB :...............x/ hari Nyeri/ rasa panas saat BAB Perdarahan Hemoroid

Konstipasi Diare

Buang Air Kecil

Frekuensi BAK :...............x/hari Kesulitan Berkemih Riwayat Penyakit Ginjal

Dorongan Penggunaan diuretik

Personal higine Frekuansi mandi :...................X/hari Frekuensi gosok gigi :...................x/hari Perawatan Payudara :...................... Vulva Higine :......................

3. PEMERIKSAAN FISIK

a. secara umum

Tanda- tanda vital Tekanan darah :......................................mm/Hg Suhu :......................................C Nadi :......................................x/ menit

Pernapasan :......................................x/ menitBerat badan sekarang :......................................KgBerat Badan sebelum lahir :..........................KgLILA :......................................Cm

b. Secara head To Toe

Kepala Rambut :........................... Muka :........................... Mata/ konjungtiva :........................... Hidung :........................... Mulut :...........................

Leher Inspeksi : Gondok :.......................................................... Palpasi : Masa :.......................................................... Auskultasi : Bruit Aorta :..........................................................

Dada Payudara membersar :....................... Puting susu :....................... Kebersihan :....................... Simetris :.......................

Abdomen Inspeksi

Straiae Gravidarum :.................................... Hiperpigmentasi :....................................

Auskultasi DJJ :..................................... Bising usus :.....................................

Palpasi Leopold I :..................................... Leopold II :..................................... Leopold III :..................................... Leopold IV :.....................................

Perkusi :.....................................

Ekstremitas Kekuatan otot :..................................... Reflek Patela :..................................... Reflek Babinski :..................................... Edema :..................................... Chubb :.....................................

c. pemeriksaan laboratorium

HB :...........................Gol. Darah:...............................................Rh+/-

Urine :..........................................................................................................

USG :..........................................................................................................

d. data penunjang therapy

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

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

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

ANALISA DATA

DATA PENYEBAB MASALAH

DO

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

.

DS

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RENCANA INTERVENSI

NO DIAGNOSA TUJUANKRITERIA

HASILINTERVENSI RASIONALISASI

IMPLEMANTASI DAN EVALUASI

NO. DIAGNOSA

HARI/TANGGAL TINDAKAN EVALUASI