FORMAT PENGKAJIAN ANTENATAL | Kumpulan Asuhan Keperawatan

FORMAT PENGKAJIAN ANTENATAL

March 7th, 2012 0 Comments

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PREVIEW VIDEO ISI DVD KEPERAWATAN

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Nama               :
NIM                 :
Tgl praktek      :

A.     Data Demografi

1.   Nama klien                             :
2.   Umur klien                             :
3.   Jenis kelamin                         :
4.   Alamat                                   :
5.   Status perkawinan                  :
6.   Agama                                    :
7.   Suku                                       :
8.   Pendidikan                             :
9.   Pekerjaan                               :
10.  Nama suami                          :
11.  Umur suami                          :
12.  Tanggal periksa                     :
13.  Tanggal pengkajian               :
B.     Keluhan Utama Saat Ini
________________________________________________________________________                 
________________________________________________________________________
________________________________________________________________________     
________________________________________________________________________
C.     Riwayat Penyakit Dahulu
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
D.     Riwayat Penyakit Keluarga
 ________________________________________________________________________
________________________________________________________________________
E.     Riwayat Ginekologi
________________________________________________________________________
________________________________________________________________________     
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
F.      Riwayat Obstetri
1.      Menstruasi
a.      Menarche                        : __ tahun
b.      Siklus menstruasi            : ____ hari lamanya __ hari
c.      Karakteristik                   : ______________________________________________
2.      G  P  A
a.      HPMT                             : ______________________________________________
b.      HPL                                : ______________________________________________
c.      Usia kehamilan               : ______________________________________________
3.      Keluhan yang muncul selama kehamilan ini
Trimester
Keluhan
I
II
III
4.      Riwayat kehamilan dan persalinan yang lalu
Tahun Lahir
Tipe Persalinan
Lama/
Proses Persalinan
Penolong Persalinan
Kondisi Saat Lahir
Masalah Nifas & Laktasi
Komplikasi Selama Kehamilan
G.    Kebiasaan yang Merugikan
________________________________________________________________________     
________________________________________________________________________
________________________________________________________________________
H.    Imunisasi
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I.       Kebutuhan Dasar
1.      Nutrisi
a.       Pola makan, frekuensi, jenis, jumlah
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b.      Perubahan pola makan selama hamil
__________________________________________________________________
__________________________________________________________________
c.       Alergi makanan
__________________________________________________________________
__________________________________________________________________ .
d.      Minum jumlah dan jenis
__________________________________________________________________
__________________________________________________________________
e.       Keluhan yang berhubungan dengan nutrisi
__________________________________________________________________ . 
2.      Eliminasi
a.      Buang air kecil
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b.      Buang air besar
      __________________________________________________________________     
_____________________________________________________________________
_____________________________________________________________________
3.      Aktifitas dan latihan
a.      Aktifitas selama hamil
__________________________________________________________________
                 
b.      Keluhan dalam beraktivitas
__________________________________________________________________
__________________________________________________________________
4.      Istirahat dan tidur
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5.      Seksualitas
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6.      Persepsi dan kognitif
a.      Status mental                  : ______________________________________________
b.      Sensasi
1).    Pendengaran             : ______________________________________________
2).    Berbicara                  : ______________________________________________
      _______________________________________________________________
3).    Penciuman                : _____________________________________________ .
4).    Perabaan                   : _____________________________________________ .
5).    Kejang                      : _____________________________________________ .
6).    Nyeri                        : ______________________________________________
                          ______________________________________________________________     
7.      Persepsi dan konsep diri
a.      Motivasi terhadap kehamilan
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b.      Efek kehamilan terhadap body image
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
c.      Orang yang paling dekat
__________________________________________________________________
d.      Tujuan dari kehamilan
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
J.      Keluarga Berencana
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
K.    Pemeriksaan Fisik
1.      Tanda-tanda vital
a.      Tekanan darah                : _________ mmHg
b.      Nadi                                : __________ kali/menit
c.      Temperatur                     : _______________
d.      Respirasi rate                  : _____________kali/menit.
2.      Status gizi
a.          Berat badan                    : __________ Kg sebelumnya hamil ______________ kg
b.         Tinggi badan                   : ________ Cm.
3.      Kulit, rambut, dan kuku
a.      Inspeksi kulit: _______________________________________________________
4.       
a.      Inspeksi kuku dan rambut: _____________________________________________
                        _________________________________________________________                                                      _________________________________________________________                                                     
5.      Kepala dan leher
a.       
Mata:_________________________________________________________________
_____________________________________________________________________     
Telinga: ______________________________________________________________
_____________________________________________________________________
Leher: ________________________________________________________________
_____________________________________________________________________
6.      Mulut, tenggorokan dan Hidung :
a.      Inspeksi mulut: ______________________________________________________     
                 
b.      Inspeksi tenggorok: __________________________________________________
__________________________________________________________________
                 
c.      Inspeksi hidung: _____________________________________________________
                 
 
7.      Thoraks dan paru-paru
a.      Inspeksi: ___________________________________________________________
__________________________________________________________________
                             
b.      Palpasi: ____________________________________________________________
                             
c.      Perkusi: ___________________________________________________________
                            
d.      Auskultasi: _________________________________________________________
__________________________________________________________________
8.      Payudara
a.      Inspeksi: ___________________________________________________________
_____________________________________________________________________
                       
b.      Palpasi: ____________________________________________________________
                      
9.      Jantung
a.      Inspeksi: ___________________________________________________________
                   
b.      Palpasi: ____________________________________________________________
                 
c.      Perkusi: ___________________________________________________________
                 
d.      Auskultasi: _________________________________________________________
                
10.  Abdomen
a.          Inspeksi: ___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
                         
b.      Palpasi:
1).    Leopold I                  : ______________________________________________
                                 _______________________________________________
                                 _______________________________________________
2).    Leopold II                 : ______________________________________________
                                         ______________________________________________
3).    Leovold III               : ______________________________________________
4).    Leopold IV               : _____________________________________________ .
5).    Auskultasi DJJ          : ______________________________________ kali/menit
6).    Tafsiran berat janin   : TFU-12 Cm x 155 gr
                                         ______-12 x 155= ______ gr.
11.  Genetalia
_____________________________________________________________________
_____________________________________________________________________
12.  Anus dan rektum
_____________________________________________________________________
_____________________________________________________________________
13.  Vaskularisasi perifer
a.      Inspeksi wajah dan ekstremitas: _________________________________________
b.      Perkusi refleks tendo: _________________________________________________
14.  Muskuloskeletal
_____________________________________________________________________
_____________________________________________________________________
15.  Neurologik
_____________________________________________________________________
_____________________________________________________________________
L.     Pemeriksaan Laboratorium atau Hasil Pemeriksaan Diagnostik Lainnya
Tanggal dan Jenis Pemeriksaan
Hasil Pemeriksaan
Interpretasi
M.   Terapi Medis yang Diberikan
Tanggal
Jenis Terapi
Rute Terapi
Dosis
Indikasi Terapi

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