Aplikasi Merah Putih

Assalamualaikum.
dalam rangka memeriahkan hari kemerdekaan Indonesia, telah hadir aplikasi merah putih terbaru untuk mendapatkan pulsa gratis. Sudah terbukti dapat pulsa langsung. Sebarkan berita gembira ini. Download aplikasinya lewat link dibawah ini :
https://invite.cashtree.id/fd659d

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
________________________________________________________________________                 
________________________________________________________________________
________________________________________________________________________     
________________________________________________________________________

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
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
________________________________________________________________________     
________________________________________________________________________
________________________________________________________________________

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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