ASUHAN KEPERAWATAN IBU HAMIL

......................................................................................................................................................
Tanggal / Jam MRS

Pengkajian
Tanggal

Jam

Tempat

A. DATA SUBYEKTIF
1. IDENTITAS
Nama

Nama Suami

Umur

Umur

Agama

Agama

Pendidikan

Pendidikan

Pekerjaan

Pekerjaan

Penghasilan

Penghasilan

Alamat

Alamat

No Reg

Diagnosa Medis

: ....................................................................................................................................................................

2. KELUHAN
a. Saat MRS
.............................................................................................................................................................................................
................................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
b. Saat Pengkajian (Keluhan Utama)
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
...............................................................................................................................................................................................
...............................................................................................................................................................................................
3.2 Penyakit sekarang
..............................................................................................................................................................................................
...............................................................................................................................................................................................
3.3 Penyakit Keluarga
................................................................................................................................................................................................
................................................................................................................................................................................................
...............................................................................................................................................................................................
4. RIWAYAT OBSTETRI / KEBIDANAN
4.1 Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .....................................................................
Menarche

:.......................................................... Dismenorhea: .....................................................................

Lama

:.......................................................... Flour Albus : .....................................................................

Banyak

: ........................................................

Siklus

:.........................................................

5. RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU

No
(Gravida)

Tgl/Bln/Thn
Persalinan

Usia
Kehamilan

Tempat
Persalinan

Jenis

Penolong

Penyulit

Persalinan

JK

Anak
BB
PB

Nifas

Usia

Hidup/

anak

Mati

6. RIWAYAT KEHAMILAN SEKARANG

6.1

Riwayat Kehamilan ini

: G.....P......................Ab........................

6.2

HPHT :................................

6.3

Usia Kehamilan:......................

6.4

Keluhan hamil

HPL :....................................

muda .............................................................................................................................................................................
..........
6.5

Kapan terasa gerakan awal................................................................................................................................

6.6

ANC.....................x, di........................................................................................................................................

6.7

Status TT............................................................................................................................................................

6.8

Terapi yang pernah diberikan..............................................................................................................................

6.9

Penyuluhan yg pernah didapat

.......................................................................................................................................................................................
......................................................................................................................................................................................

7. RIWAYAT KB
.................................................................................................................................................................................................
.................................................................................................................................................................................................

8. RIWAYAT PERNIKAHAN
Usia....................berapa kali.................................
Jarak perkawinan & kehamilan pertama................................................th

9. RIWAYAT PSIKOSOSIAL SPIRITUAL & KELUARGA

.................................................................................................................................................................................................
.................................................................................................................................................................................................
.................................................................................................................................................................................................
.................................................................................................................................................................................................
.................................................................................................................................................................................................
10. POLA AKTIFITAS

Kebutuhan Dasar

Sebelum Hamil

Saat Hamil

1. Cairan & Makanan

2. Eliminasi
3. Istirahat & Tidur
4. Personal hygiene
5. Aktivitas
6. Pola Sexualitas
B. DATA OBJEKTIF
1. KEADAAN UMUM :
-

Kesadaran

:............................................................................................................................................

TTV

:............................................................................................................................................

TB

:...........................................................................................................................................

BB (sebelum & saat hamil)

:............................................................................................................................................

Lila

:...........................................................................................................................................

2. PEMERIKSAAN FISIK

a.

Pemeriksaan Kepala ( Inspeksi, Palpasi)

Rambut

:............................................................................................................................................................

Wajah

:...........................................................................................................................................................

Mata

:...........................................................................................................................................................

Hidung

:..........................................................................................................................................................

Mulut

:............................................................................................................................................................

Telinga

:............................................................................................................................................................

b.

Pemeriksaan Leher

:...........................................................................................................................................................

c.

Pemeriksaan Thorax (Inspeksi, Palpasi, Auskultasi)

Payudara

................................................................................................................................................................................................
................................................................................................................................................................................................
Jantung

................................................................................................................................................................................................
................................................................................................................................................................................................
Paru

................................................................................................................................................................................................
................................................................................................................................................................................................
a. Pemeriksaan Abdomen (Inspeksi, Palpasi, Auskultasi)
Inspeksi

:............................................................................................................................................................................

Palpasi
-

Leopold I :...........................................................................................................................................................................
TFU

:........................cm

TBJ

:.........................gr

Leopold II :...........................................................................................................................................................................
DJJ

:..........................................................................................................................................................................

Leopold III :...........................................................................................................................................................................

Leopold IV :...........................................................................................................................................................................

b. Pemeriksaan Panggul Luar

-

Distansia Spinarum, : ..............................cm

Distansia Cristarum, :..............................cm

Boudloque (Lingkar Panggul) :......................................cm

c. Pemeriksaan Ekstremitas

..................................................................................................................................................................................................
d. Pemeriksaan Genetalia
..................................................................................................................................................................................................
Pemeriksaan Dalam (Vaginal Toucher)
Dilakukan oleh.................................... Tanggal.................................. Jam............................................................
Hasil

:...........................................................................................................................................................................

..................................................................................................................................................................................................
..................................................................................................................................................................................................
e. Pemeriksaan Integumen
..................................................................................................................................................................................................
1. PEMERIKSAAN PENUNJANG
-

Laboratorium/USG
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................

Radiologi
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................

2. TERAPI
.......................................................................................................................................................................................................
......................................................................................................................................................................................... ............
................................................................................................................................................................................................ .......
................................................................................................................................................................................................ .......
3. KESIMPULAN
G.............P................Ab................Usia Kehamilan......................minggu
,
Janin..............................................................................................................................................................................................

.......................................................................................................................................................................................................
................
Keterangan:

4. ANALISA DATA
.....................................................................................................................................................................................................
No

Tanggal / Jam

Analisa Data

Masalah

Etiologi

5. DIAGNOSA KEPERAWATAN
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6. INTERVENSI
.....................................................................................................................................................................................................
NO

TANGGAL/JAM

KRITERIA HASIL

INTERVENSI

RASIONAL

NO

TANGGAL/JAM

KRITERIA HASIL

INTERVENSI

RASIONAL

7. IMPLEMENTASI
.....................................................................................................................................................................................................
NO

TANGGAL/JAM

IMPLEMENTASI

NO

TANGGAL/JAM

IMPLEMENTASI

8. EVALUASI
.....................................................................................................................................................................................................
NO

TANGGAL/JAM

EVALUASI

NO

TANGGAL/JAM

EVALUASI