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ASUHAN KEPERAWATAN IBU HAMIL ......................................................................................................................................................

ASUHAN KEPERAWATAN IBU HAMIL ......................................................................................................................................................

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 3.1Penyakit yang lalu ............................................................................................................................................................................................... .................................................................................................................................................................. ............................. 3.2Penyakit sekarang .............................................................................................................................................................................................. .................................................................................................................................................................. ............................. 3.3Penyakit Keluarga
3.
RIWAYAT KESEHATAN
3.1Penyakit yang lalu
...............................................................................................................................................................................................
..................................................................................................................................................................
.............................
3.2Penyakit sekarang
..............................................................................................................................................................................................
..................................................................................................................................................................
.............................
3.3Penyakit Keluarga
................................................................................................................................................................................................
................................................................................................................................................................................................
..................................................................................................................................................................
.............................
4.
RIWAYAT OBSTETRI / KEBIDANAN
4.1Riwayat Menstruasi
Amenorhea
Menarche :..........................................................
Teratur/tdk
: .....................................................................
Dismenorhea: .....................................................................
Lama :..........................................................
Flour Albus
: .....................................................................
Banyak
: ........................................................
Siklus :.........................................................
5.
RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU
No
Tgl/Bln/Thn
Usia
Tempat
Jenis
Penolong
Penyulit
Anak
Nifas
Usia
Hidup/
JK
BB
PB
(Gravida)
Persalinan
Kehamilan
Persalinan
Persalinan
anak
Mati
6.
RIWAYAT KEHAMILAN SEKARANG
6.1
Riwayat Kehamilan ini
: G
.....
P ......................Ab........................
6.2
HPHT :
................................
HPL :
....................................
  • 6.3 Usia Kehamilan: ......................

  • 6.4 Keluhan hamil 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 ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... 6. INTERVENSI .....................................................................................................................................................................................................
    • 5. DIAGNOSA KEPERAWATAN ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... ..................................................................................................................................................................................................... .....................................................................................................................................................................................................

    • 6. INTERVENSI

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

    NO

    TANGGAL/JAM

    KRITERIA HASIL

    INTERVENSI

    RASIONAL

           
    NO TANGGAL/JAM KRITERIA HASIL INTERVENSI RASIONAL

    NO

    TANGGAL/JAM

    KRITERIA HASIL

    INTERVENSI

    RASIONAL

           
    7. IMPLEMENTASI ..................................................................................................................................................................................................... NO TANGGAL/JAM IMPLEMENTASI

    7.

    IMPLEMENTASI

     

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

    NO

    TANGGAL/JAM

    IMPLEMENTASI

       
     

    NO

    TANGGAL/JAM

    IMPLEMENTASI

       

    8.

    EVALUASI

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

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

    NO

    TANGGAL/JAM

    EVALUASI

       
         

    NO

    TANGGAL/JAM

    EVALUASI