FORMAT PENGKAJIAN ANTENATAL

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

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C.     Riwayat Penyakit Dahulu

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D.     Riwayat Penyakit Keluarga

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E.     Riwayat Ginekologi

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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

No	Tahun Lahir	Tipe Persalinan	Lama/ Proses Persalinan	Tempat/ Penolong Persalinan	BBL	Kondisi Saat Lahir	Masalah Nifas & Laktasi	Komplikasi Selama Kehamilan

G.    Kebiasaan yang Merugikan

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H.    Imunisasi

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I.       Kebutuhan Dasar

1.      Nutrisi

a.       Pola makan, frekuensi, jenis, jumlah

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__________________________________________________________________

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b.      Perubahan pola makan selama hamil

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c.       Alergi makanan

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__________________________________________________________________ .

d.      Minum jumlah dan jenis

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e.       Keluhan yang berhubungan dengan nutrisi

__________________________________________________________________ . 

2.      Eliminasi

a.      Buang air kecil

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__________________________________________________________________

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b.      Buang air besar

      __________________________________________________________________     

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3.      Aktifitas dan latihan

a.      Aktifitas selama hamil

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b.      Keluhan dalam beraktivitas

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4.      Istirahat dan tidur

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5.      Seksualitas

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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

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b.      Efek kehamilan terhadap body image

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c.      Orang yang paling dekat

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d.      Tujuan dari kehamilan

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J.      Keluarga Berencana

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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: ______________________________________________________________

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Leher: ________________________________________________________________

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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

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13.  Vaskularisasi perifer

a.      Inspeksi wajah dan ekstremitas: _________________________________________

b.      Perkusi refleks tendo: _________________________________________________

14.  Muskuloskeletal

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15.  Neurologik

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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