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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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