FORMAT ASKEP IBU HAMIL (ANC)

PENGKAJIAN
I. IDENTITAS
Nama ibu

Umur

Pendidikan

Agama
Pekerjaan

Nama suami :
Umur
Pendidikan
:

Status perkawinan
Alamat

Agama
Pekerjaan

:
:
:
:

Tanggal pengkajian

Diagnosa medis :
2. DATA SUBJEKTIF
a. keluhan utama
............................................................................................................
............................................................................................................
......................................................
b. riwayat Kesehatan Sekarang
............................................................................................................
............................................................................................................
......................................................
c. Riwayat Kehamilan Sekarang
ANC(Ante Natal Care)
:.........................teratur/tidak.................................................
Diperiksa
.................

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

Imunisasi
...............

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

Usia kehamilan
: .............................................................................................
d. Riwayat Menstruasi
Menarche
r/tidak...........

....................siklus......................lamanya..........teratu

Jumlah :......................Warna:..................dismenorhe:......................
.............
HPHT

:......................taksiran persalinan persalinan..............

e. Riwayat obstetri
G.............................P.................................A................................
.........................
ANA
K KE

JENKE
L

UMU
R

RIWAYAT PERSALINAN
LANI
R

USIA
HAMI
L

PENOLON
G

f. Riwayat Kesehatan / Penyakit Yang lalu

PENYULI
T

BB
L

KE
T

penyakit
alergi
merokok dan obat-obatan
g. Riwayat penyakit Keluarga
............................................................................................................
............................................................................................................
......................................................
h. Keadaan Psikososial

Perubahan kehamilan terhadap kehidupan sehari-hari.

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

Harapan yang didinginkan selama kehamilan

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

Ibu tinggal serumah dengan siapa

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

Yang menemani ibu ke klinik

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

Rencana melahirkan
...................................................................................................
........................

Rencana menyusui
...................................................................................................
........................

i. Seksual
dampak kehamilan terhadap perubahan pola
seksual ...................................................................................................
.......................................
j. riwayat keluarga Berencana
Jenis kontrasepsi yang pernah digunakan
.................................................................................................
................................
Masalah-masalah yang dailami selama kehamilan
..................................................................................................
................................
Jumlah anak yang direncanakan
...................................................................................................
...............................

k. pola kehidupan sehari-hari

Pola makan
Diet kebiasaan (jenis)
...................................................................................................
.........................
Perubahan dalam pola makan
...................................................................................................
.........................
Pandangan selama kehamilan terhadap makanan
...................................................................................................
.........................
Masalah mengunyah/menelan
...................................................................................................
.........................
Kenyamanan, aktivitas dan istirahat
Kenyamanan selama kehamilan dan cara mengatasinya
...................................................................................................
.........................
Aktivitas/hobi kebiasaan
...................................................................................................
.........................
Aktivitas kesenangan
...................................................................................................
......................... Pembatasan selama kehamilan kondisi
...................................................................................................
.........................
Perubahan istirahat, tidur,dan cara mengatasinya
...................................................................................................
........................ Jumlah jam istirahat/ tidur perhari
...................................................................................................
......................... Pola eleminasi
Buang Air Besar

Dampak kehamilan terhadap pola eleminasi

Frekuensi BAB :...............x/ hari

Nyeri/ rasa panas saat BAB
Perdarahan
Hemoroid
Konstipasi
Diare

Buang Air Kecil

Frekuensi BAK
:...............x/hari
Kesulitan Berkemih
Riwayat Penyakit Ginjal
Dorongan
Penggunaan diuretik
Personal higine
Frekuansi mandi :...................X/hari
Frekuensi gosok gigi
:...................x/hari
Perawatan Payudara
:......................
Vulva Higine
:......................
3. PEMERIKSAAN FISIK
a. secara umum
Tanda- tanda vital
Tekanan darah :......................................mm/Hg
Suhu
:......................................C
Nadi
:......................................x/ menit
Pernapasan
:......................................x/ menit
Berat badan sekarang :......................................Kg
Berat Badan sebelum lahir
:..........................Kg
LILA
:......................................Cm
b. Secara head To Toe

Kepala
Rambut
:...........................
Muka
:...........................
Mata/ konjungtiva
:...........................
Hidung
:...........................
Mulut
:...........................
Leher
Inspeksi
: Gondok
:..........................................................
Palpasi
: Masa
:..........................................................

 Auskultasi
: Bruit Aorta
:..........................................................
Dada
Payudara membersar :.......................
Puting susu
:.......................
Kebersihan
:.......................
Simetris
:.......................
Abdomen
Inspeksi
Straiae Gravidarum
:....................................
Hiperpigmentasi :....................................
Auskultasi
DJJ
:.....................................
Bising usus
:.....................................
Palpasi
Leopold I
:.....................................
Leopold II
:.....................................
Leopold III
:.....................................
Leopold IV
:.....................................
Perkusi
:.....................................

Ekstremitas
Kekuatan otot
:.....................................
Reflek Patela
:.....................................
Reflek Babinski :.....................................
Edema
:.....................................
Chubb
:.....................................
c. pemeriksaan laboratorium
HB

:...........................Gol. Darah
:...............................................Rh+/ Urine
:...................................................................................
.......................
USG
:..........................................................................
................................
d. data penunjang therapy
..............................................................................................................
..............................................................................................................
..............................................................................................................
....................................................................................

ANALISA DATA
DATA

PENYEBAB

MASALAH

DO
............................
........
DS
............................
.......

RENCANA INTERVENSI

NO

DIAGNOS
A

TUJUA
N

KRITERI
A HASIL

INTERVEN
SI

RASIONALISA
SI

IMPLEMANTASI DAN EVALUASI

NO.
DIAGNOSA

HARI/TANGGAL

TINDAKAN

EVALUASI