pengkajian mater

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


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) : ...................................................................................


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


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


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 :

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