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Format Pengkajian Antenatal
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FORMAT PENGKAJIAN ANTENATALDiposkan oleh Rizki Kurniadi
Nama :NIM :Tgl praktek :
A. Data Demografi1. 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 Obstetri1. Menstruasia. Menarche : __ tahunb. Siklus menstruasi : ____ hari lamanya __ haric. Karakteristik :______________________________________________2. G P Aa. HPMT :______________________________________________b. HPL :______________________________________________c. Usia kehamilan :______________________________________________
3. Keluhan yang muncul selama kehamilan iniTrimester Keluhan
I
II
III
4. Riwayat kehamilan dan persalinan yang laluNo
Tahun
Lahir
Tipe Persalina
n
Lama/Proses
Persalinan
Tempat/Penolong Persalina
n
BBL
Kondisi Saat Lahir
Masalah Nifas
& Laktasi
Komplikasi Selama
Kehamilan
G. Kebiasaan yang Merugikan
________________________________________________________________________ ________________________________________________________________________________________________________________________________________________
H. Imunisasi
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I. Kebutuhan Dasar
1. Nutrisia. 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. Eliminasia. Buang air kecil
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
b. Buang air besar __________________________________________________________________ __________________________________________________________________________________________________________________________________________
3. Aktifitas dan latihana. Aktifitas selama hamil
__________________________________________________________________
b. Keluhan dalam beraktivitas____________________________________________________________________________________________________________________________________
4. Istirahat dan tidur_______________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________5. Seksualitas
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Persepsi dan kognitifa. Status mental :______________________________________________b. Sensasi
1). Pendengaran :______________________________________________2). Berbicara :______________________________________________
_______________________________________________________________3). Penciuman :_____________________________________________ .4). Perabaan :_____________________________________________ .5). Kejang :_____________________________________________ .
6). Nyeri :______________________________________________ ______________________________________________________________
7. Persepsi dan konsep diria. 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 vitala. Tekanan darah : _________ mmHgb. Nadi : __________ kali/menitc. Temperatur : _______________d. Respirasi rate : _____________kali/menit.
2. Status gizia. 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 lehera.
Mata:______________________________________________________________________________________________________________________________________ Telinga:___________________________________________________________________________________________________________________________________Leher:_____________________________________________________________________________________________________________________________________
6. Mulut, tenggorokan dan Hidung :a. Inspeksi mulut:______________________________________________________
b. Inspeksi tenggorok:__________________________________________________
__________________________________________________________________
c. Inspeksi hidung:_____________________________________________________
7. Thoraks dan paru-parua. Inspeksi:___________________________________________________________
__________________________________________________________________
b. Palpasi:____________________________________________________________
c. Perkusi:___________________________________________________________
d. Auskultasi:___________________________________________________________________________________________________________________________
8. Payudaraa. Inspeksi:___________________________________________________________
_____________________________________________________________________
b. Palpasi:____________________________________________________________
9. Jantunga. 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/menit6). Tafsiran berat janin : TFU-12 Cm x 155 gr
______-12 x 155= ______ gr.11. Genetalia
__________________________________________________________________________________________________________________________________________
12. Anus dan rektum__________________________________________________________________________________________________________________________________________
13. Vaskularisasi perifera. 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