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KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN
PROGRAM PROFESI NERS
Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816
ASUHAN KEPERAWATAN KLIEN PADA MASA KEHAMILAN
TANGGAL PENGKAJIAN: NAMA MAHASISWA/I:
TANGGAL MASUK RS : NIM :
NO.REGISTER : TANDA TANGAN :
RUANGAN :
DIAGNOSA MEDIS :
I. BIODATA
1. Nama :.........................................................................................
2. Umur :..............................................Pendidikan.........................
3. Suku Bangsa :.........................................................................................
4. Alamat :.........................................................................................
...............................................................................................................................................
5. Nama Suami :.........................................................................................
6. Agama :.........................................................................................
7. Pekerjaan :.........................................................................................
II. RIWAYAT KESEHATAN
1. Keluhan Utama/Alasan MRS :.........................................................................................
2. Riwayat Kesehatan Sekarang :.........................................................................................
...............................................................................................................................................
...............................................................................................................................................
3. Penyakit terdahulu yang mempengaruhi kehamilan :...........................................................
...............................................................................................................................................
4. ANC/Antenatal Care : I / II / III / IV
5. Riwayat Haid :.........................................................................................
a. Menarche :................................................................
b. Haid Terakhir/HPHT :....................................................Taksiran
partus.
c. Siklus Haid : Teratur / Tidak Teratur (28 hari, 30 hari, 35 hari)
d. Lama :.........................................................................................
e. Banyaknya :.........................................................................................
f. Masalah :.........................................................................................
Masalah Keperawatan :
6. Riwayat Kontrasepsi
a. Jenis Alat Kontrasepsi yang digunakan :.............................................................................
b. Kapan Menggunakan :.............................................................................
c. Masalah :.............................................................................
7. Riwayat kehamilan yang lalu
a. Gravid :.......................... Para :.......................... Abortus :............................
b. Jumlah anak yang hidup :.............................................................................
c. Siapa yang menolong persalinan :.......................................Dimana.........................
d. Komplikasi yang terjadi sewaktu kehamilan yang lalu :
1) Tidak Ada
2) Ada, Sebutkan (..............................................................................................................)
e. Komplikasi yang terjadi waktu persalinan dan kehamilan
1) Sectio casaria....................................................Penyebab................................................
2) Perdarahan.........................................................Jumlah ..................................................
3) Kejang .............................................................................................................................
4) Persalinan Lama...............................................................................................................
f. Masalah waktu nifas :
1) Perdarahan.................................................................................................................
2) Infeksi........................................................................................................................
3) Anemia......................................................................................................................
g. Masalah pada bayi yang dilahirkan :
1) Apgar Score :.........................................................................................
2) Gangguan Pernafasan :.........................................................................................
3) Icterus :.........................................................................................
4) Lahir Mati :.........................................................................................
8. Riwayat Pengobatan/Rokok/Alkohol :
a. Obat yang digunakan :
b. Tujuan pengobatan :
c. Ketergantungan dengan rokok :
d. Penggunaan alkohol :
e. Jenis imunisasi selama hamil :..................................Kapan pemberian......................
9. Masalah yang dirasakan/keluhan :
a. Mual : YA / TIDAK Muntah : YA / TIDAK
b. Nyeri ulu hati :.............................................................................
c. Gangguan BAK :.............................................................................
d. Pendarahan :.............................................................................
e. Gangguan tidur dan istirahat :.............................................................................
f. Kram pada kaki/kejang :.............................................................................
g. Pusing/sakit kepala :.............................................................................
h. Kelelahan :.............................................................................
i. Obstipasi :.............................................................................
j. Sakit Pinggang :.............................................................................
Masalah Keperawatan :
10. Pola kegiatan sehari-hari
a. Istirahat dan Tidur
1) Malam hari ................Jam Siang hari....................Jam
2) Apakah ada gangguan................................... Jenis gangguan..............................
b. Personal Hygiene
1) Berapa kali mandi................................................................................................
2) Perawatan gigi...................................................Berapa kali sikat gigi.................
c. Aktivitas
1) Apakah ada gangguan dalam pergerakan/jalan....................................................
d. Makanan dan Minuman
1) Berapa kali makan sehari...........................................Nafsu makan.....................
2) Pantangan.............................................................................................................
3) Diet.......................................................................................................................
e. Eliminasi
1) Masalah BAB.......................................................................................................
2) Diare/Konstipasi...................................................................................................
3) Masalah BAK.......................................................................................................
f. Seksual
1) Apakah ada perubahan : YA................. TIDAK.......................................
2) Jenis perubahan yang dialami:.............................................................................
Masalah Keperawatan :
III.PSIKOSOSIAL
1. Status emosi : Stabil................................ Labil.................................................
2. Status Perkawinan :......................................Usia waktu menikah..............................
3. Rencana dan persepsi terhadap kehamilan
a. Direncanakan : YA / TIDAK
b. Diharapkan : YA / TIDAK
c. Jenis anak yang diharapkan :................................................................
d. Orang yang paling penting bagi klien :.................................................................
e. Rencana tempat melahirkan :.................................................................
f. Rencana mengikuti senam hami :.................................................................
g. Rencana memberikan ASI : YA / TIDAK
Masalah Keperawatan :
IV. RIWAYAT KESEHATAN KELUARGA :.................................................................
V. PEMERIKSAAN FISIK
1. Tanda-tanda vital
a. Tekanan Darah :..............................
b. Nadi :..............................
c. Suhu :..............................
d. Respirasi :...............................
2. Berat badan............................ kg Tinggi badan...................................... cm
3. Kulit
a. Warna.................................................
b. Kekenyalan.........................................
c. Perlukaan............................................
d. Hyperpigmentasi.................................
4. Rambut
Warna:............................................Distribusi..................................................................
5. Kepala
a. Ukuran seimbang dengan badan (Ya/Tidak) :.....................................................
b. Pergerakaan sendi (Ya/Tidak) :.....................................................
6. Leher
a. Pembesaran kelenjar tiroid (Ya/Tidak) :.....................................................
b. Pembesaran Vena Jugularis (Ya/Tidak) :.....................................................
7. Mata
Konjungtiva :................................... Anemia :.................................
8. Hidung
Apakah ada kelainan :....................................
9. Gigi dan Mulut :.....................................
10. Bentuk Dada :.....................................
11. Buah Dada :
a. Bentuk buah dada Kiri....................................... Kanan.............................................
b. Konsisionsi (keras/lembut) :.......................................................................................
c. Simetris dalam ukuran kiri/kanan (Ya/Tidak)............................................................
d. Pembesaran Kiri/Kanan (Ya/Tidak)...........................................................................
e. Hyperpigmentasi aerola dan putting (Ya/Tidak)........................................................
f. Putting susu menonjol (Ya/Tidak).............................................................................
g. Pembesaran pembuluh vena (Ya/Tidak)....................................................................
h. Kolostrum (ada/tidak)................................................................................................
12. Abdomen
a. Pembesaran Kiri/Kanan (Ya/Tidak)...........................................................................
b. Bentuk perut...............................................................................................................
c. Linea nigra..................................................................................................................
d. Striae albikan..............................................................................................................
e. Perlukaan....................................................................................................................
f. Jaringan Perut.............................................................................................................
g. Palpasi (Leopold).......................................................................................................
I :.............................................................................................................................
II :.............................................................................................................................
III :.............................................................................................................................
IV :.............................................................................................................................
h. Mc. Donald rule :.....................................cm
i. Auskultasi :
1) Frekuensi :...........................................
2) Regularity :...........................................
3) Lokalisasi :...........................................
j. Pergerakan anak :...........................................
13. Panggul luar (untuk primi para)
a. Distansia spinarum (23 cm) :......................................cm
b. Distansia cristarum (26 cm) :......................................cm
c. Boudelequa (16 cm) :......................................cm
d. Ukuran Lingkar Pinggang (80 cm) :.....................................cm
14. Ekstremitas
a. Ukuran kaki simetris :............................................
b. Warna Kuku (Kaki/Tangan) :.............................................
c. Edema (Kaki/Tangan) :.............................................
d. Refleks Tungkai Bawah :.............................................
e. Varises :.............................................
15. Vulva
a. Edema :..........................................
b. Varises :..........................................
c. Luka :...........................................
d. Pengeluaran cairan:............................................
e. Warna :.............................................
16. Rectum
varises :.....................................................................
Masalah Keperawatan :
VI. PEMERIKSAAN KHUSUS
1. Laboratorium
a. Urine :...............................................
Test Kehamilan :................................................
b. Darah :................................................
WR :.................................................
HB/ GoL Darah :.................................................
2. Diagnostik Kehamilan :...................................................................................
Yang Melakukan Pengkajian
(...........................................)
NIM.
Nama Mahasiswa :.......................................................
NIM :.......................................................
Mata Kuliah :........................................................
ANALISA DATA
NO DATA
KEMUNGKINAN
PENYEBAB/WOC
MASALAH
DIAGNOSA KEPERAWATAN
NO TGL/JAM DIAGNOSA KEPERAWATAN PARAF
PELAKSANAAN TINDAKAN KEPERAWATAN
NO DX TGL/JAM TINDAKAN KEPERAWATAN PARAF
EVALUASI
MASALAH
KEPERAWATAN
TGL/
JAM
CATATAN PERKEMBANGAN PARAF
S :
O:
A
P
KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN
PRODI PROFESI NERS
Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816
FORMAT PENGKAJIAN KELUARGA BERENCANA
TANGGAL PENGKAJIAN: NAMA MAHASISWA/I:
TANGGAL MASUK RS : NIM :
NO.REGISTER : TANDA TANGAN :
RUANGAN :
I. BIODATA
1. Nama :.........................................................................................
2. Umur :..............................................Pendidikan.........................
3. Suku Bangsa :.........................................................................................
4. Alamat :.........................................................................................
...............................................................................................................................................
5. Nama Suami :.........................................................................................
6. Agama :.........................................................................................
7. Pekerjaan :.........................................................................................
II. RIWAYAT KESEHATAN
1. Keluhan Utama/Alasan datang ke PKM.........................................................................
2. Riwayat Kesehatan Sekarang :.........................................................................................
...............................................................................................................................................
...............................................................................................................................................
3. JUMLAH ANAK
NO Tanggal lahir anak Tipe persalinan Keadaan
sekarang
Ket
1
2
3
4
4. Menstruasi Terakhir :…………………………………………………………………
5. Lama Perkawinan :………………………………………………………………….
6. Masalah waktu hamil :………………………………………………………….
7. Masalah setelah melahirkan :………………………………………………………
8. Riwayat Kontrasepsi
a. Apakah sudah pernah memakai alat kontrasepsi sebelumnya
:……………………………………………………………………………………
b. Memakai alat kontrasepsi jenis apa :……………………………………………….
c. Adakah masalah dengan menggunakan metode KB tersebut
:……………………………………………………………………………………
Jika ya , sebutkan :
9. Riwayat Kesehatan :
a. Masalah kesehatan yg dialami saat ini :………………………………………..
b. Apakah dalam pengobatan:……………………………………………………
c. Apakah pernah menderita infeksi vagina / panggul:………………………..
10. Rencana metode kontrasepsi yang akan digunakan klien dan pasangan
:……………………………………………………………………………………..
11. Analisa data
12. Diagnosa Keperawatan, NCP,Implementasi dan Evaluasi ( sesuai format askep)

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Format pengkajian masa kehamilan ners

  • 1. KEMENTERIAN KESEHATAN RI POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN PROGRAM PROFESI NERS Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816 ASUHAN KEPERAWATAN KLIEN PADA MASA KEHAMILAN TANGGAL PENGKAJIAN: NAMA MAHASISWA/I: TANGGAL MASUK RS : NIM : NO.REGISTER : TANDA TANGAN : RUANGAN : DIAGNOSA MEDIS : I. BIODATA 1. Nama :......................................................................................... 2. Umur :..............................................Pendidikan......................... 3. Suku Bangsa :......................................................................................... 4. Alamat :......................................................................................... ............................................................................................................................................... 5. Nama Suami :......................................................................................... 6. Agama :......................................................................................... 7. Pekerjaan :......................................................................................... II. RIWAYAT KESEHATAN 1. Keluhan Utama/Alasan MRS :......................................................................................... 2. Riwayat Kesehatan Sekarang :......................................................................................... ............................................................................................................................................... ............................................................................................................................................... 3. Penyakit terdahulu yang mempengaruhi kehamilan :........................................................... ...............................................................................................................................................
  • 2. 4. ANC/Antenatal Care : I / II / III / IV 5. Riwayat Haid :......................................................................................... a. Menarche :................................................................ b. Haid Terakhir/HPHT :....................................................Taksiran partus. c. Siklus Haid : Teratur / Tidak Teratur (28 hari, 30 hari, 35 hari) d. Lama :......................................................................................... e. Banyaknya :......................................................................................... f. Masalah :......................................................................................... Masalah Keperawatan : 6. Riwayat Kontrasepsi a. Jenis Alat Kontrasepsi yang digunakan :............................................................................. b. Kapan Menggunakan :............................................................................. c. Masalah :............................................................................. 7. Riwayat kehamilan yang lalu a. Gravid :.......................... Para :.......................... Abortus :............................ b. Jumlah anak yang hidup :............................................................................. c. Siapa yang menolong persalinan :.......................................Dimana......................... d. Komplikasi yang terjadi sewaktu kehamilan yang lalu : 1) Tidak Ada 2) Ada, Sebutkan (..............................................................................................................) e. Komplikasi yang terjadi waktu persalinan dan kehamilan 1) Sectio casaria....................................................Penyebab................................................
  • 3. 2) Perdarahan.........................................................Jumlah .................................................. 3) Kejang ............................................................................................................................. 4) Persalinan Lama............................................................................................................... f. Masalah waktu nifas : 1) Perdarahan................................................................................................................. 2) Infeksi........................................................................................................................ 3) Anemia...................................................................................................................... g. Masalah pada bayi yang dilahirkan : 1) Apgar Score :......................................................................................... 2) Gangguan Pernafasan :......................................................................................... 3) Icterus :......................................................................................... 4) Lahir Mati :......................................................................................... 8. Riwayat Pengobatan/Rokok/Alkohol : a. Obat yang digunakan : b. Tujuan pengobatan : c. Ketergantungan dengan rokok : d. Penggunaan alkohol : e. Jenis imunisasi selama hamil :..................................Kapan pemberian...................... 9. Masalah yang dirasakan/keluhan : a. Mual : YA / TIDAK Muntah : YA / TIDAK b. Nyeri ulu hati :............................................................................. c. Gangguan BAK :............................................................................. d. Pendarahan :............................................................................. e. Gangguan tidur dan istirahat :............................................................................. f. Kram pada kaki/kejang :.............................................................................
  • 4. g. Pusing/sakit kepala :............................................................................. h. Kelelahan :............................................................................. i. Obstipasi :............................................................................. j. Sakit Pinggang :............................................................................. Masalah Keperawatan : 10. Pola kegiatan sehari-hari a. Istirahat dan Tidur 1) Malam hari ................Jam Siang hari....................Jam 2) Apakah ada gangguan................................... Jenis gangguan.............................. b. Personal Hygiene 1) Berapa kali mandi................................................................................................ 2) Perawatan gigi...................................................Berapa kali sikat gigi................. c. Aktivitas 1) Apakah ada gangguan dalam pergerakan/jalan.................................................... d. Makanan dan Minuman 1) Berapa kali makan sehari...........................................Nafsu makan..................... 2) Pantangan............................................................................................................. 3) Diet....................................................................................................................... e. Eliminasi 1) Masalah BAB....................................................................................................... 2) Diare/Konstipasi................................................................................................... 3) Masalah BAK....................................................................................................... f. Seksual 1) Apakah ada perubahan : YA................. TIDAK.......................................
  • 5. 2) Jenis perubahan yang dialami:............................................................................. Masalah Keperawatan : III.PSIKOSOSIAL 1. Status emosi : Stabil................................ Labil................................................. 2. Status Perkawinan :......................................Usia waktu menikah.............................. 3. Rencana dan persepsi terhadap kehamilan a. Direncanakan : YA / TIDAK b. Diharapkan : YA / TIDAK c. Jenis anak yang diharapkan :................................................................ d. Orang yang paling penting bagi klien :................................................................. e. Rencana tempat melahirkan :................................................................. f. Rencana mengikuti senam hami :................................................................. g. Rencana memberikan ASI : YA / TIDAK Masalah Keperawatan : IV. RIWAYAT KESEHATAN KELUARGA :................................................................. V. PEMERIKSAAN FISIK 1. Tanda-tanda vital a. Tekanan Darah :.............................. b. Nadi :.............................. c. Suhu :..............................
  • 6. d. Respirasi :............................... 2. Berat badan............................ kg Tinggi badan...................................... cm 3. Kulit a. Warna................................................. b. Kekenyalan......................................... c. Perlukaan............................................ d. Hyperpigmentasi................................. 4. Rambut Warna:............................................Distribusi.................................................................. 5. Kepala a. Ukuran seimbang dengan badan (Ya/Tidak) :..................................................... b. Pergerakaan sendi (Ya/Tidak) :..................................................... 6. Leher a. Pembesaran kelenjar tiroid (Ya/Tidak) :..................................................... b. Pembesaran Vena Jugularis (Ya/Tidak) :..................................................... 7. Mata Konjungtiva :................................... Anemia :................................. 8. Hidung Apakah ada kelainan :.................................... 9. Gigi dan Mulut :..................................... 10. Bentuk Dada :..................................... 11. Buah Dada : a. Bentuk buah dada Kiri....................................... Kanan............................................. b. Konsisionsi (keras/lembut) :.......................................................................................
  • 7. c. Simetris dalam ukuran kiri/kanan (Ya/Tidak)............................................................ d. Pembesaran Kiri/Kanan (Ya/Tidak)........................................................................... e. Hyperpigmentasi aerola dan putting (Ya/Tidak)........................................................ f. Putting susu menonjol (Ya/Tidak)............................................................................. g. Pembesaran pembuluh vena (Ya/Tidak).................................................................... h. Kolostrum (ada/tidak)................................................................................................ 12. Abdomen a. Pembesaran Kiri/Kanan (Ya/Tidak)........................................................................... b. Bentuk perut............................................................................................................... c. Linea nigra.................................................................................................................. d. Striae albikan.............................................................................................................. e. Perlukaan.................................................................................................................... f. Jaringan Perut............................................................................................................. g. Palpasi (Leopold)....................................................................................................... I :............................................................................................................................. II :............................................................................................................................. III :............................................................................................................................. IV :............................................................................................................................. h. Mc. Donald rule :.....................................cm i. Auskultasi : 1) Frekuensi :........................................... 2) Regularity :........................................... 3) Lokalisasi :........................................... j. Pergerakan anak :........................................... 13. Panggul luar (untuk primi para)
  • 8. a. Distansia spinarum (23 cm) :......................................cm b. Distansia cristarum (26 cm) :......................................cm c. Boudelequa (16 cm) :......................................cm d. Ukuran Lingkar Pinggang (80 cm) :.....................................cm 14. Ekstremitas a. Ukuran kaki simetris :............................................ b. Warna Kuku (Kaki/Tangan) :............................................. c. Edema (Kaki/Tangan) :............................................. d. Refleks Tungkai Bawah :............................................. e. Varises :............................................. 15. Vulva a. Edema :.......................................... b. Varises :.......................................... c. Luka :........................................... d. Pengeluaran cairan:............................................ e. Warna :............................................. 16. Rectum varises :..................................................................... Masalah Keperawatan : VI. PEMERIKSAAN KHUSUS 1. Laboratorium a. Urine :............................................... Test Kehamilan :................................................
  • 9. b. Darah :................................................ WR :................................................. HB/ GoL Darah :................................................. 2. Diagnostik Kehamilan :................................................................................... Yang Melakukan Pengkajian (...........................................) NIM.
  • 10. Nama Mahasiswa :....................................................... NIM :....................................................... Mata Kuliah :........................................................ ANALISA DATA NO DATA KEMUNGKINAN PENYEBAB/WOC MASALAH
  • 11. DIAGNOSA KEPERAWATAN NO TGL/JAM DIAGNOSA KEPERAWATAN PARAF
  • 12. PELAKSANAAN TINDAKAN KEPERAWATAN NO DX TGL/JAM TINDAKAN KEPERAWATAN PARAF
  • 14. KEMENTERIAN KESEHATAN RI POLITEKNIK KESEHATAN JAMBI JURUSAN KEPERAWATAN PRODI PROFESI NERS Jl. Dr. Tazar Buluran Kenali Telanai Pura Jambi. Telp. (0741) 65816 FORMAT PENGKAJIAN KELUARGA BERENCANA TANGGAL PENGKAJIAN: NAMA MAHASISWA/I: TANGGAL MASUK RS : NIM : NO.REGISTER : TANDA TANGAN : RUANGAN : I. BIODATA 1. Nama :......................................................................................... 2. Umur :..............................................Pendidikan......................... 3. Suku Bangsa :......................................................................................... 4. Alamat :......................................................................................... ............................................................................................................................................... 5. Nama Suami :......................................................................................... 6. Agama :......................................................................................... 7. Pekerjaan :......................................................................................... II. RIWAYAT KESEHATAN 1. Keluhan Utama/Alasan datang ke PKM......................................................................... 2. Riwayat Kesehatan Sekarang :......................................................................................... ............................................................................................................................................... ...............................................................................................................................................
  • 15. 3. JUMLAH ANAK NO Tanggal lahir anak Tipe persalinan Keadaan sekarang Ket 1 2 3 4 4. Menstruasi Terakhir :………………………………………………………………… 5. Lama Perkawinan :…………………………………………………………………. 6. Masalah waktu hamil :…………………………………………………………. 7. Masalah setelah melahirkan :……………………………………………………… 8. Riwayat Kontrasepsi a. Apakah sudah pernah memakai alat kontrasepsi sebelumnya :…………………………………………………………………………………… b. Memakai alat kontrasepsi jenis apa :………………………………………………. c. Adakah masalah dengan menggunakan metode KB tersebut :…………………………………………………………………………………… Jika ya , sebutkan : 9. Riwayat Kesehatan : a. Masalah kesehatan yg dialami saat ini :……………………………………….. b. Apakah dalam pengobatan:…………………………………………………… c. Apakah pernah menderita infeksi vagina / panggul:……………………….. 10. Rencana metode kontrasepsi yang akan digunakan klien dan pasangan :…………………………………………………………………………………….. 11. Analisa data
  • 16. 12. Diagnosa Keperawatan, NCP,Implementasi dan Evaluasi ( sesuai format askep)