ANC & INC

FORMAT PENGKAJIAN ANTE NATAL CAREMAHASISWA PROGRAM PROFESI NERSSTIKES NANI HASANUDDIN MAKASSAR

No. Reg. Ibu : ............................. Nama Mahasiswa :............................Tgl. Kunjungan : .............................. Tgl. Pengkajian :..............................

I. BIODATA

A. IDENTITAS IBU / SUAMI : Nama : ....................................../........................................... Umur : ................tahun / .....................tahun Suku / bangsa : ...................................../ ........................................... Agama : ...................................../ ........................................... Pend. Terakhir : ...................................../ ........................................... Pekerjaan : ...................................../ ................................. Lamanya menikah:............................................................................... Alamat : ...................................................................................

B. DATA BIOLOGIS / FISIOLOGIS1. Keluhan utama ( mual/muntah, pusing/sakit kepala, keluar darah,

dll) :...................................................................................................................................................................................................................................................................................................................................

2. Riwayat keluhan :a. Mulai

timbulnya ........................................................................................................b. Sifat

keluhan(kwalitas/kwantitas) .........................................................................................................

c. Lokasi keluhan .................................................................................d. Faktor pencetus................................................................................e. Keluhan lain .....................................................................................f. Pengaruh keluhan terhadap aktifitas / fungsi

tubuh .........................................................................................................g. Usaha klien untuk mengatasi

keluhan ........................................................................................................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).......................................................................

Riwayat uterus........................................................................................... Abdominal.................................................................................................

e. Riwayat tranfusi darah ( kapan, alasan, reaksi ) :......................................................................................................

4. Riwayat kehamilan dan persalinan serta nifas yang lalu :

NoKehamilan Persalinan Anak

Riwayat Nifas

Umur Keadaan Thn Tempat Penolong Jenis P/L Lamanya menyusui

Keadaan skrg

5. Pola Reproduksi :a. Menarche umur :......................................................................................b. Siklus haid :......................................................................................c. Lamanya haid :......................................................................................d. Sifat darah :......................................................................................e. Dysmenorhoe :......................................................................................

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

Iodine .........................................2) Nafsu makan .........................................................................................3) Masalah dengan gigi/mengunyah .........................................................4) Makanan yang disenangi ......................................................................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) Incontinensia uri :...................................................3) Dysuri :..................................................................4) Hemoroid :.............................................................5) Konstipasi :...........................................................6) Perubahan

lain........................................................................................ :..............................................................................................................

c. Kebutuhan kebersihan diri sendiri :Kebiasaan :1) Kebersiahan rambut : ................................................2) Kebersihan badan :....................................................3) Kebersihan gigi/mulut :.............................................4) Kebersihan genetalia dan anus :.......................................5) Kebersihan kuku tangan/kaki :..................................6) Kebersihan pakaian :.................................................Perubahan selama hamil.............................................................................. :.........................................................................................................................................................................................................................................

d. Kebutuhan rekreasi / olah raga :Kebiasaan :1) Jenis / frekuensi rekreasi : .........................................2) Jenis / fekuensi olah raga :.........................................3) Jenis rekreasi / olah raga :..........................................Perubahan selama hamil :............................................................................ ..........................................................................................................................................................................................................................................

e. Kebutuhan istirahat /tidur :

Kebiasaan :1) Istirahat/tidur siang :..............................................2) Istirahat/tidur malam :...........................................3) Pekerjaan RT dilakukan : .....................................4) Merawat anak dilakukan :....................................Selama hamil :1) Perubahan :............................................................................................

...............................................................................................................2) Peranan keluarga dalam membantu ibu istirahat :................................

:..............................................................................................................f. Kebutuhan seksual ( bila mungkin / perlu )

1) Kebiasaan : ...........................................................................................

2) Perubahan selama hamil : ..................................................................... ...............................................................................................................

7. Pemerikasaan Fisika. Pemeriksaan fisik umum :

1) Penampilan ibu : ......................................................2) Kesadaran : ..............................................................3) Tinggi/BB: ...................Cm / ....................Kg4) Tanda Vital :

Tekanan darah : .......................mmHg Denyut nadi : .........................../menit Temperatur : ...........................oC Respirasi : ................................/menit

5) Inspeksi kepala dan rambut : Keadaan rambut : ................................................. Kebersihan rambut : .............................................

6) Inspeksi wajah/muka : Edema wajah/muka : ............................................ Topeng kehamilan : ............................................. 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 : .......................................- Suhu payudara : ...............................

b. Jantung- Ictus cordis : .......................................- Bunyi tambahan : ...............................

c. Paru- Bunyi pernafasan : .............................- Bunyi tambahan : ..............................

d. Abdomen- Pembesaran : ..........................................................- Bentuk : .................................................................- Striae : ...................................................................- Linea : ...................................................................- Tanda hidramnion : ...............................................- Tampak gerakan janin : ........................................- Peristaltik usus : ..................................................

13) Inspeksi genetalia (vulva/anus)a. Kebersihan : ................................................................b. Tanda chadwick : ........................................................c. Varises : .......................................................................d. Flour albus : .................................................................e. Pembesaran kel. lipat paha : ........................................

14) Inspeksi dan palpasi tungkai bawah :a. Kesimetrisan : .............................................................b. Edema : ........................................................c. Varises : .....................................................................

b. Pemeriksaan Obstetri

1. PalpasiLeopol Ia. Tinggi Fundus Uteri : ...............................................Leopol IIb. Posisi janin : .............................................................Leopol IIIc. Presentasi janin : ......................................................Leopol IVd. Masuknya presentasi : ............................................

2. Auskultasi DJJa. Irama/regularitas : ..................................................b. Frekuensi :.........................................kali / menitc. Gerakan janin : .....................................................d. Bising uterus : .......................................................e. Bunyi aorta : ..........................................................f. Gerakan usus : .......................................................

3. Pemeriksaan panggul (tgl pengukuran)a. Distansia spinarum : ...............cmb. Distansia kristarum : ...............cmc. Konjugata eksterna : ................cmd. Konjugata diagonalis : .............cme. Distansia tuberum : ..................cmf. Ukuran lingkar panggul : ..........cm

4. Pemerikasaan laboratorium (hasil tgl)a. Urine :

- Albumin : ................................- Reduksi : .................................

b. Darah :- HB- Golongan darah- Lain-lain

c. Keluarga Berencana- Apakah ibu mengerti tentang KB : ...........................................- Apakah ibu setuju dengan KB : ...............................................- Apakah ibu pernah menjadi akseptor : .....................................- Apakah metode kontrasepsi yang digunakan : .........................- Apakah pernah drop out : ...................alasannya......................

........................d. Data Psikologis /sosiologis

a. Reaksi emosional terhadap kehamilan- Rencana untuk hamil : ...........................................- Respon ibu : ..........................................................- Respon suami : ......................................................- Respon anak : ........................................................

b. Peranan ibu dalam keluarga

- pengambilan keputusan : ......................................- konsultasi kesehatan : ..........................................- Penentuan diet dan makan pantang : ....................- Lain-lain : ..............................................................

e. Data Spritual1. Hubungan keyakinan ibu dengan kehamilannya :....................

..................................................................2. Usaha ibu untuk berdoa terhadap kesehatannya :.....................

.....................................................................................3. Pantangan menurut keyakinan ibu selama kehamilan :............

....................................................................................4. Keharusan menurut keyakinan ibu selam kehamilan :..............

....................................................................................f. Data tambahan lain :

1. Keluarga klien : ........................................................................2. Tim kesehatan yang terlibat :....................................................

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

Makassar, ....... .....................2013Mahasiswa yang bersangkutan,

(.............................................)

FORMAT PENGKAJIAN INTRA NATAL CAREMAHASISWA PROGRAM PROFESI NERSSTIKES NANI HASANUDDIN MAKASSAR

I. BIODATAa. Identitas istri / ibu :

Nama : ................................................................... Umur : ................................................................... Suku / bangsa : ................................................................... Agama : ..................................................................... Pendidikan terakhir : ........................................................................ Pekerjaan : ........................................................... Penghasilan / bln : ................................................................... Status perkawinan : .................................................................. Lamanya : ...................................................................... Perkawinan yang ke : ................................................................. Alamat : ................................................................... Tanggal kunjungan : ...................................................................

b. Identitas Suami : Nama : .................................................................. Umur : ................................................................... Suku / bangsa : ................................................................... Agama : .................................................................... Pendidikan terakhir : ................................................................... Pekerjaan : ............................................................... Penghasilan / bln : ................................................................. Status perkawinan : .................................................................. Lamanya : ................................................................... Perkawinan yang ke : ................................................................... Alamat : ..................................................................

II. DATA BIOLOGIS / FISIOLOGISa. Keluhan utama : ...........................................................................................................b. Riwayat keluhan utama : ..............................................................................................c. Riwayat kehamilan sekarang :

G : ................................ P : ........................................ A : ..................................... .............................................tafsiran persalinan ..................................................... Jam berapa uterus mulai berkontraksi : .................................................................. Interaksi His ......................................Interval His .................................................

d. Riwayat kehamilan dan persalinan serta nifas yang lalu

NoKehamilan Persalinan Anak

Riwayat Nifas

Umur Keadaan Thn Tempat Penolong Jenis P/L Lamanya menyusui

Keadaan skrg

e. Pola Reproduksi : Menarche umur ...................................................................................................... Sikluis haid ..............................................teratur /tidak ......................................... Lamanya haid ......................................................................................................... Sifat darah .............................................................................................................. Dysmenorhoe .........................................................................................................

f. Riwayat kesehatan Riwayat penyakit yang pernah dialami / terutama yang berpengaruh terhadap

kehamilan................................................................................................................ Riwayat operasi yang pernah dialami .................................................................... Riwayat keluhan ;

a. Penyakit : TBC, hepatitis, kejiwaan, malaria, DM atau penyalit lainnya ..........................................................................................................................

b. Kehamilan kembar ...........................................................................................g. Pola kegiatan sehari-hari

1. Nutrisi : Jenis makanan .................................................................................................. Frekuensi makanan sehari ................................................................................ Nafsu makan .................................................................................................... Makanan pantang ............................................................................................. Makanan kesukaan ........................................................................................... Banyaknya minum sehari..................................................................................

2. Eliminasi :b. Buang air besar :

Frekuensi............................................... Warna ................................................... Konsistensi .........................................

c. Buang air kecil : Frekuensi ............................................ Warna ................................................. Jumlahnya ..........................................

3. Istirahat (tidur) : Tidur waktu malam berapa jam (dari pukul.................s/d.....................) Tidur waktu siang berapa jam ( dari pukul ................s/d .....................)

4. Kebersihan diri : Penampilan umum ..................................................................................... Mandi / hari ............................................................................................... Sikat gigi / hari .......................................................................................... Cuci rambut / minggu ............................................................................... Ganti pakaian dalam dan luar sehari ..........................................................

5. Rekreasi / olah raga atau hobby ;............................................................................ :................................................................................................................................

6. Ketergantungan : Obat .................................................................... Rokok ................................................................. Minuman keras ...................................................

7. Hubungan seksual, keluhan :...................................................................................8. Riwayat Keluarga Berencana : ...............................................................................

Mengerti tentang KB ..................................................................................... Setuju tentang KB ......................................................................................... Pernah menjadi akseptor ................................................................................. Drop out, alasannya .........................................................................................

h. Pemeriksaan fisika. Tanda-tanda vital :

Tekanan darah ................................mmHg Suhu .............................oC Pernafasan ................../menit Nadi ............................/ menit

b. Berat badan ......................Tinggi badan ..............................c. Cara berjalan ........................................................................d. Kesadaran umum .................................................................e. Inspeksi :

1. Kepala- Rambut ...................................................................

2. Muka- Pucat : ................................................- Kloasma gravidarum : .................................................- Sianosis : .....................................................- Udema : .....................................................

3. Mata- Kelopak mata : ......................................................- Skelera mata : .....................................................- Konjungtiva : .....................................................

4. Mulut dan gigi- Berbau : .................................kebersihan ................................- Jumlah gigi : ...................................................................................- Caries : ................................................- Stomatitis : ................................................

5. Leher- Pembesaran kelenjar : ........................................................................

6. Buah dada- Bentuknya : ...................................kebersihan .........................- Keadaan puting susu : ..............................................................................- Pengeluaran kolestrum: ..............................................................................

7. Perut- Bentuknya : ..................................linea/strias.............................- Bakas luka operasi : ................................................................................

8. Vulva- Udema : tanda chadwick ..............................................- Pengeluaran dari vagina : ........................................................................- Kebersihan : ........................................................................

9. Tungkai- Varises : ..............................................................................................- Udema : ...............................simetris .................................................

f. Pemeriksaan panggul luar dan perut1. Lingkar panggul : ...........................................................2. Lingkar perut : ...........................................................3. Distensia cristarum : ...........................................................4. Boudologue : ...........................................................

g. Palpasi :1. Tinggi Fundus Uteri : ..........................................................

h. Auskultasi :1. Bunyi jantung janin : ..........................................................2. Frekuensi : ..........................................................3. Lokasi paling jelas : .........................................................4. Gerak janin : .........................................................5. Bising rahim : .........................................................6. Bunyi aorta : .............................................................7. Bunyi jantung ibu : ............................................................8. Bunyi paru ibu : ............................................................

i. Perkusi :- Refleks patella :

Kanan ............................kiri ...........................- Babinsky :...............................

- Tricep/bicep..........................................j. Pemeriksaan laboratorium

1. Urine :- Albumin- Reduksi- Plano test

2. Darah :- Golongan darah- HB- VDRL

k. Pemeriksaan rontgen : ...............................................................................III. RIWAYAT PERSALINAN SEKARANG

a. Kala I1. Lamanya : ..................................j

am ......................menitPelepasan tgl : ...................................jam ...............................

2. Tanda Vital- Telanan darah : ............................nadi ...................................- Pernafasan : ..................................

3. Palpasi menurut Leopold :- TFU : .........................................................................- Punggung janin : .........................................................................- Bagian yang terdepan : .........................................................................- Turunnya bagian terendah : .........................................................................

4. His (kontraksi uteri )- Tanggal : .................................jam .................................- Frekuensi : .................................lamanya..........................- Intensitas (kekuatannya :..........................................................................

5. Vaginal toucher :- Dilakukan oleh : .........................................................................- Indikasi : .........................................................................- Tanggal : .........................................................................- Pembukaan : .........................................................................- Serviks : .........................................................................- Ketuban : .........................................................................- Bagian paling bawah : .........................................................................- Presentasio : .........................................................................- Turunnya hodge : .........................................................................- Kesan panggul : .........................................................................- Rektum : ........................................................................- Pelepasan : .........................................................................

b. Kala II1. Lamanya : .................................jam .......................menit2. His intensitasnya : .........................................................................

3. Denyut Jantung Janin (DJJ) : frekuensi ....................jumlahnya ...................- Bagian paling depan : .....................presentasio .................................- Turunnya : .....................kesan panggul ............................- Pelepasan lendir : .........................................................................- Ketuban pecah : .................................oleh ................................- Warnanya : .............baunya...................ju

mlahnya............- Keadaan His : .........................keadaan

perineum..................- Ibu mulai mengedan : .........................caranya

mengedan .................- Bayi lahir tanggal

: ................................jam ..................................- Jenis persalinan

: .........................................................................- Perdarahan : .................................................

........................4. Keadaan bayi:

- Apgar skor : 1 menit setelah lahir : .....................................- 5 menit : .........................................................................- Berat badan lahir : ..........................panjang badan ......................- Cacat bawaan : .........................................................................- Caput suksadenum : .........................................................................- Cephal hematom : .........................................................................- Setelah 5 menit lahir apakkah ada mekonium : ...............................................

c. Kala III1. Lamanya : .................................................

.....menit2. TFU setelah bayi lahir : .........................................................................3. Katerisasi urine

: ........................................................................4. Kontraksi urine

: .........................................................................5. Lahirnya placenta

: .........................................................................6. Pemeriksaan placenta :

- Kotiledon : .........................................................................

- Beratnya : .........................................................................

- Tali pusat : Panjang : ....................cm Keadaan : ...............................

- Tanda Vital :

Tekanan darah : .......................mmHg Nadi : ......................./ menit Pernafasan : ....................../ menit Suhu : .....................oC

- Perdarahan : .........................................................................

IV. DATA PSIKOLOGIS1. Pola interaksi.................................................................................................................2. Reaksi dan persepsi terhadap kehamilan ......................................................................

- Direncanakan .........................................................................................................- Apakah klien cemas dengan persalinannya ............................................................- Jenis kelamin yang diharapkan ..............................................................................- Bantuan pelayanan yang diharapkan ......................................................................- Kebutuhan kesehatan yang diharapakan ................................................................

Perawatan payudara agar ASI cukup untuk kebutuhan bayi Bimbingan tentang perawatan bayi

- Pelayanan yang telah diberikan :............................................................................. ..................................................................................................................................................................................................................................................................

V. DATA SOSIAL1. Bagaimana hubungan terhadap keluarga......................................................................2. Bagaimana hubungan terhadap tetangga / masyararat .................................................3. Bagaiman hubungan dengan pasien yang di rawat di rumah sakit ..............................4. Siapa yang paling terpenting bagi pasien .....................................................................5. Siapa yang menanggung perawatan .............................................................................

VI. DATA SPRITUAL1. Keyakinan kepada Tuhan YME2. Ketaatan dalam melaksanakan ibadah sekarang

Makassar, .............................................Mahasiswa yang bersangkutan,

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