FORMAT PENGKAJIAN ANTENATAL

MAHASISWA PROGRAM STUDI KEPERAWATAN

UNIVERSITAS MANDALA WALUYA

No.Reg.Ibu :......................... Nama Mahasiswa :.............

Tgl.Kunjungan :......................... Tgl.Pengkajian :.............

I. BIODATA
A. IDENTITAS IBU / SUAMI
a. Nama :.................................../..............................
b. Umur :....................tahun/.......................tahun
c. Suku/bangsa :................................../...............................
d. Agama :................................./................................
e. Pend.trakhir :................................./................................
f. Pekerjaan :................................./................................
g. Lamanya nikah :..................................................................
h. Alamat :..................................................................
B. DATA BIOLOGIS/FISIOLOGIS
1. Keluhan Utama (mual/muntah,pusing/sakit kepala, keluar darah dll)
:.........................................................................................................
..........................................................................................................
2. Riwayat Keluhan :
a. Mulai Timbulnya..........................................................................
b. Sifat Keluhan ( Kualitas/Kuantitas).............................................
c. Lokasi Keluhan............................................................................
d. Faktor Pencetus..........................................................................
e. Keluhan Lain...............................................................................
f. Pengaruh Keluhan terhadap aktifitas/Fungsi tubuh...................
g. Usaha Klien untuk mengatasi keluhan.......................................
h. Efektifitas tindakan yang di lakukan...........................................
3. Riwayat kesehatan masa Lalu
a. Penyakit yang pernah di derita...................................................
b. Riwayat opname ( kapan/alasan)...............................................
c. Riwayat Trauma (kapan/alasan).................................................
d. Riwayat operasi (kapan/alasan)....................................................
e. Riwayat transfusi darah (kapan,alasan , reaksi )..........................
4. Riwayat Kehamilan dan Persalinan serta nifas yang lalu
No Kehamilan Persalinan Anak Riway
Umur Keadaan Thn Tempat Penolong Jenis P/L Lamanya Keadaan at
Menyusui sekarang Nifas
5. Pola Reproduksi
a. Menarche umur :......................................................................
b. Siklus Haid :......................................................................
c. Lamanya Haid :......................................................................
d. Sifat Darah :......................................................................
e. Dismenorhea :......................................................................
6. Riwayat Pola kegiatan Sehari-hari
a. Nutrisi
Kebiasaan:
1. Pola makan......................................................
2. Frekuensi makanan sehari..........................................................
3. Kebutuhan Minuman/cairan........................................................
Selama Hamil :
1. Konsumsi perhari Makanan sumber :
 Karbohidrat....................................
 Protein.............................................
 Lemak.............................................
 Besi/asam folat...............................
 Kalsium..........................................
2. Nafsu Makan............................................................
3. Masalah dengan gigimengunyah.............................
4. Makanan yang di senangi.........................................
5. Makanan yang di pantang.........................................
6. Keluhan minum/cairan..............................................
7. Perubahan lain..........................................................
b. Eliminasi
Kebiasaan:
1. Frekuensi BAK :.........................................................
2. Warna/bau Khas :......................................................
3. Gangguan Eliminasi (BAK);.......................................
4. Frekuensi BAB:..........................................................
5. Warna/Konsistensi BAB:...........................................

Selama Hamil :
1. Poliuri:.......................................................................
2. Inkontinensia Urine:..................................................
3. Dysuri :......................................................................
4. Hemoroid :................................................................
5. Konstipasi :...............................................................
6. Perubahan Lain :......................................................
c. Kebutuhan kebersihan diri sendiri
Kebiasaan:
1. Kebersihan Rambut:................................................
 2. Kebersihan Badan:..................................................
3. Kebersihan gigi/mulut :............................................
4. Kebersihan Genitalia dan Anus:..............................
5. Kebersihan Kuku tangan/kaki:.................................
6. Kebersihan pakaian:................................................
Perubahan Selama Hamil.........................................................
d. Kebutuhan Rekreasi/olahraga :
Kebiasaan :
1. Jenis/frekuensi rekreasi :.....................................................
2. Jenis/frekuensi olahraga :....................................................
3. Jenis rekreasi/olahraga :......................................................
Perubahan Selama Hamil:........................................................
e. Kebutuhan istirahat /tidur :
Kebiasaan :
1. Istirahat / tidur siang:............................................................
2. Istirahat/Tidur malam:..........................................................
3. Pekerjaan RT di lakukan :...................................................
4. Merawat anak di lakukan :...................................................
Selama Hamil :
1. Perubahan :.........................................................................
2. Peranan Keluargadalam membantuibu istirahat:................
f. Kebutuhan Seksual ( Bila Mungkin/perlu)
1. Kebiasaan :.........................................................................
2. Perubahan Selama Hamil:..................................................
7. Pemeriksaan Fisik
a. Pemeriksaan Fisik Umum:
1. Penampilan Ibu :.................................................................
2. Kesadaran:..........................................................................
3. Tinggi/BB:........................Cm/..........................................Kg
4. Tanda Vital :
 Tekanan Darah:............................mmHg
 Nadi:............................................./menit
 Suhu:.............................................0C
 RR:.............................................../Menit
5. Inspeksi Kepala dan Rambut :
 Keadaan Rambut:......................................................
 Kebersihan Rambut:..................................................

6. Inspeksi Wajah/Muka
 Edema Wajah/Muka :...............................................
 Ekspresi Wajah:........................................................
7. Mata
 Kebersihan:..............................................................
 Konjungtiva:.............................................................
  Sklera:.....................................................................
 Kelopak Mata:.........................................................
8. Inspeksi Hidung
 Kesimetrisan :.........................................................
 Sekret Hidung:........................................................
 Epistaksis:..............................................................
9. Inspeksi gigi dan Hidung :
 Kebersihan gigi/mulut:............................................
 Keadaan Gigi:.........................................................
 Keadaan Gusi........................................................
 Keadaan Lidah.......................................................
 Keadaan Mukosa bibir...........................................
 Caries/Protese:......................................................
10. Inspeksi Telinga
 Kebersihan Telinga...............................................
 Sekret Telinga.......................................................
 Keadaan Telinga Luar...........................................
11. Inspeksi /palpasi leher :
 Pembesaran Kelenjar gondok:.............................
 Pembesaran Vena Jugularis:...............................
 Pembesaran Arteri Karotis:..................................
12. Inspeksi /Palpasi dan Auskultasi dada/perut :
a. Payudara :
 Kesimetrisan:...............................
 Keadaan Puting:..........................
 Keadaan Areola:..........................
 Kolostrum:...................................
b. Jantung :
 Ictus Cordis:............................................
 Bunyi Tambahan:....................................
c. Paru :
 Bunyi Pernafasan:..................................
 Bunyi Tambahan:...................................
d. Abdomen
a. Uterus
1) Tinggi Fundus Uteri..................................... cm
2)Kontraksi : Ya/ Tidak
3)Leopold I : ............................................................................
4)Leopold II: ............................................................................
5)Leopold III: ............................................................................
6)Leopold IV: ...........................................................................
b. Pigmentasi
1) Linea Nigra : ................................................................
2) Striae : ............................................................................
 3) Fungsi pencernaan: ........................................................
13. Inspeksi genetalia ( Vulva/Anus)
a. Vagina varises : Ya/Tidak
b. Kebersihan :.....................................................................
c. Tanda Chadwick :..........................................................
d. Flour albus :....................................................................
1) Jenis/ warna : ............................................
2) Konsistensi : ..............................................
3) Bau :....................................................
e. Hemorrhoid : ...................................................
14. Inspeksi dan palpasi Tungkai Bawah
a. Kesimetrisan :....................................................................
b. Edema Pretibial :.........................................................
c. Varises :...................................................................
c. Pemeriksaan Obstetri
1. Pemeriksaan Panggul
a. Distansia Spinarum :.........................cm
b. Distansia Kristarum :.........................cm
c. Konjungata eksterna :.........................cm
d. Konjungata Diagonalis :................... ...cm
e. Distansia tuberum :.........................cm
f. Ukuran Lingkar Panggul:....................cm

2. Pemeriksaan Laboratorium
a. Urine
- Albumin :................................
- Reduksi :................................
b. Darah
- Hb : ……………………….
- Golongan darah : …………………
c. Data Psikologis / sosiologis
1. Reaksi Emosional terhadap kehamilan
- Rencana untuk hamil :,................................
- Respon Ibu :.................................
- Respon Suami :.................................
- Respon Anak :.................................
2. Peranan Ibu dalam keluarga
- Pengambilan Keputusan :................................
- Konsultasi kesehatan :................................
- Penentuan diet dan makan Pantang:..................
d. Data Spiritual
1. Hubungan keyakinan ibu dengan kehamilannya
…………………………….
…………............................................................................................
 ...........
2. Usaha ibu untuk berdoa terhadap kesehatannya
…………………………… ..................................................................
.....................................................
3. Pantangan menurut keyakinan ibu selama kehamilan
……………………… .........................................................................
...............................................
Keharusan menurut keyakinan ibu selama kehamilan
……………………….. ....................................................................................................................
....