Selasa, 13 Maret 2012

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL KEPERAWATAN MATERNITAS

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN PRE NATAL
KEPERAWATAN MATERNITAS


Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal :
Pengkajian :
Praktik :
I. IDENTITAS PASIEN
Nama : ......................................................................................
Umur : ......................................................................................
Status Perkawinan : ......................................................................................
Agama : ......................................................................................
Suku : ......................................................................................
Pendidikan : ......................................................................................
Nama Suami : ......................................................................................
Umur Suami : ......................................................................................
Alamat : ......................................................................................
Pekerjaan : ......................................................................................
Diagnosa Medis : ......................................................................................
Tanggal Masuk RS : ......................................................................................
II. KELUHAN UTAMA
....................................................................................................................................
III. RIWAYAT PENYAKIT DAHULU
....................................................................................................................................
IV. RIWAYAT PENYAKIT KELUARGA
....................................................................................................................................
V. RIWAYAT GINEKOLOGI
....................................................................................................................................
VI. RIWAYAT OBSTETRI
§ Menarche usia : ......................................................................................
§ Siklus Menstruasi : teratur/ tidak,............hari.
§ Karakteristik mens : ......................................................................................
§ G.....P.....A.....
§ HPMT : ......................................................................................
§ HPL : ......................................................................................
§ Keluhan selama kehamilan ini
Trimester I : ..................................................................................................
Trimester II : ..................................................................................................
Trimester III : ..................................................................................................
VII. KEBIASAAN YANG MERUGIKAN
Merokok [ ] Obat-obat terlarang [ ]
Alkohol [ ] Obat-obat yang dijual bebas [ ]
VIII. KELUARGA BERENCANA
....................................................................................................................................
IX. KEBUTUHAN DASAR MANUSIA
§ NUTRISI
................................................................................................................................. ELIMINASI
.................................................................................................................................
§ ISTIRAHAT DAN TIDUR
.................................................................................................................................
§ SEKSUALITAS
.................................................................................................................................
§ PERSEPSI DAN KOGNITIF
................................................................................................................................. KONSEP DIRI
X. PEMERIKSAAN FISIK
Keadaan Umum
§ Kesadaran : ..................................................................................................
§ BB : .......kg (kenaikan BB selama hamil : ......kg), TB :........m
§ Tanda Vital : P :.........x/menit T : .........°C
R : ........x/menit BP : .........mmHg
§ Kulit
Linea nigrae [ ] Cloasma [ ]
Striae gravidarum [ ] Pucat [ ]
Angioma [ ] Eritema [ ]
§ Kuku dan kaki
Oedema [ ]
Lainnya : ..................................................................................................
§ Kepala
Sklera : ..................................................................................................
Konjungtiva : ..................................................................................................
Palpebra : ..................................................................................................
Pembesaran limphe nodi : ...........................................................................
Pembesaran kelenjar tiroid : ...........................................................................
Telinga : ..................................................................................................
THT : ..................................................................................................
§ Thoraks
Jantung : ..................................................................................................
Paru : ..................................................................................................
Payudara : ..................................................................................................
§ Abdomen
.................................................................................................................................
§ Perineum
.................................................................................................................................
§ Muskuloskeletal
.................................................................................................................................
§ Syaraf
.................................................................................................................................
XI. INFORMASI LAIN
....................................................................................................................................
XII. ANALISA DATA
DATA
PROBLEM
ETIOLOGY












Tidak ada komentar:

Posting Komentar