Selasa, 30 April 2013

format ANC


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No. Register                            : ………………………….
Masuk RS tanggal / jam          : ………………………….
Dirawat diruang                      : ………………………….


I.    PENGKAJIAN  Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......
A.    IDENTITAS
                                    Ibu                                                       Suami
Nama                           : ...................................................       ...................................................
Umur                           : ...................................................       ...................................................
Agama                         : ...................................................       ...................................................
Suku/Bangsa               : ...................................................       ...................................................
Pendidikan                  : ...................................................       ...................................................
Pekerjaan                     : ...................................................       ...................................................
Alamat                                    : ...................................................       ...................................................
No. Telp                      : ...................................................       ...................................................

B.     DATA SUBYEKTIF
1.      Alasan kunjungan
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2.      Keluhan utama
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………………………………………………………………………………...
3.      Riwayat menstruasi
Menarche        : ….. tahun                              Siklus              :..................hari 
Lama               : ….. hari                                 Teratur             :.........................
Sifat darah      : ……………..……..              Keluhan           : …………..…..

4.      Riwayat pernikahan
Status pernikahan : ......................       Menikah ke     : ….....................
Lama               : …… tahun               Usia menikah pertama kali :……. Tahun
           

5.      Riwayat obstetrik: G..... P..... A..... Ah......
Hamil ke-
Persalinan
Nifas
Tanggal
Umur khamiln
Jns prsalinan
Penolong
komplikasi
JK
BB Lahir
Laktasi
Komplikasi




















































6.      Riwayat kontrasepsi yang digunakan
No.
Jenis Kontrasepsi
Pasang
Lepas
Tgl
Oleh
Tempat
Keluhan
Tgl.
Oleh
Tempat
Alasan































7.      Riwayat kehamilan sekarang
a. HPHT: ..........................                                          HPL : ........
b.ANC pertama umur kehamilan        : .......... minggu
c.Kunjungan ANC
   Trimester I   
  Frekuensi  :….. x, Tempat :…….………………… Oleh ..................
  Keluhan    : ..........................................................................................
  Terapi       :…………………………………………….......................
  Trimester II
 Frekuensi   :….. x, Tempat :…….………………….Oleh : ................
 Keluhan     :...........................................................................................
             Terapi        : ………………………………………..............................
 Trimester III
Frekuensi   :….. x, Tempat :…….…………………. Oleh : ….............
Keluhan     :............................................................................................
Terapi        : ……………………………………...................................



d. Imunisasi TT
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e. Pergerakan janin selama 12 jam(dalam sehari)
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8.      Riwayat kesehatan

a.       Penyakit yang pernah /sedang diderita (menular, menurun dan menahun)
………………………………………………………………………………..………………………………….............…………………………………....................
b.      Penyakit yang pernah /sedang diderita keluarga (menular, menurun dan menahun)
…………………………………………………………………………………..… ……………………………….............…………………………………………....
c.       Riwayat keturunan kembar
                 …………………………………………………………………………………….
d.      Riwayat operasi
                 …..………………………………………………………………………………...
e.       Riwayat alergi obat
                  …………………………………………................................................................
9.      Pola pemenuhan kebutuhan sehari-hari
a.Pola nutrisi    sebelum hamil                                     saat  hamil
   Makan
         Frekuensi      : .......x/hari                                          ........x/hari
         Porsi             : ..................................                        ...............................    
                           Jenis              : ..................................                        ...............................
                          Pantangan     : ..................................                        ...............................
        Keluhan         : ..................................                        ...............................
        Minum                                                          
        Frekuensi       : .......x/hari,                                         .........x/hari                 
        Porsi              : ...................................                       ..............................
        Jenis              : ...................................                       ..............................
        Pantangan     : ...................................                       ..............................
        Keluhan         : ...................................                       ..............................



   b.Pola eliminasi
      BAB
      Frekuensi         : ................................                          ...............................
      Konsistesi        : ................................                          ...............................
      Warna              : ................................                          ...............................
      Keluhan           : …............................                          ...............................

      BAK
      Frekuensi         : .................................                         ..............................
      Konsistesi        : .................................                         ..............................
      Warna              : .................................                         ..............................
      Keluhan           : ….............................                         ..............................
                     c.            Pola istirahat
Tidur siang
Lama               : ..... jam/hari                                       .........jam/hari             
Keluhan           : ................................                          ......................
Tidur malam
Lama               : ..... jam/hari                                       .........jam/hari                         
Keluhan           : ...............................                           ......................
        d. Personal hygiene
Mandi              : ..... x/hari                                           ......x/hari                    
Ganti pakaian  : ...... x/hari                                          ......x/hari
Gosok gigi       : ...... x/hari                                          .......x/hari
Keramas          : ...... x/minggu                                    ......x/minggu
  e.Pola seksualitas
     Frekuensi          : ..... x/minggu                                     ......x/minggu              
     Keluhan            : .............................
f. Pola aktivitas (terkait kegiatan fisik, olah raga)
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10.  Kebiasaan yang mengganggu kesehatan ( merokok,minum jamu,minuman beralkohol)
…………………………………………………………………………………………..
…………………………………………………………………………………………..
…………………………………………………………………………………………..
………………………………………………………………………………………….
11.  Psikososiospiritual ( penerimaan ibu/suami/keluarga terhadap kehamilan ,dukungan sosial,perencanaan persalinan,pemberian ASI,perawatan bayi,kegiatan ibadah,kegiatan sosial,dan persiapan keuangan ibu dan keluarga)
………………………………………………………………………………………….
………………………………………………………………………………………….
………………………………………………………………………………………….
…………………………………………………………………………………………
12.  Pengetahuan ibu ( tentang kehamilan,persalinan,dan laktasi)
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
13.  Lingkungan yang berpengaruh ( sekitar rumah dan hewan peliharaan)
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C.   DATA OBYEKTIF
1.    Pemeriksaan umum
Keadaan umum    : ....................................                     
Kesadaran                        : ....................................
Status emosional  : ....................................
Tanda vital sign :
            Tekanan darah : ................. mmHg                 Nadi                : ................ x/menit
            Pernapasan      : ................. x/menit                Suhu                : ................ x/menit
Berat badan     : ................. kg                        Tinggi badan   : ................ cm

2.    Pemeriksaan fisik
Kepala                  : ......................................................................................................................
       Rambut                 : ......................................................................................................................
       Muka                    : ......................................................................................................................
       Mata                     : ................., sklera ..............................., konjungtiva ....................................
       Hidung                 : ......................................................................................................................
       Mulut                    : ......................................................................................................................
       Telinga                  : ......................................................................................................................
       Leher                    : ......................................................................................................................
       Dada                     : ...................................................................................................................... Payudara             : ......................................................................................................................
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       Abdomen             : ......................................................................................................................
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            Palpasi Leopold
              Leopold I      : ………..........................................................................................................
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              Leopold II    : ......................................................................................................................
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              Leopold III   : ......................................................................................................................
              Leopold IV   : ......................................................................................................................
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            Osborn test                              : ..............................................................................................
            TFU menurut Mc. Donald       : ....... cm,        TBJ      : ..........................................................
            Auskultasi DJJ                         : ..............................................................................................   
       Ekstremitas atas   : ......................................................................................................................
       Ekstremitas bawah            : ......................................................................................................................
       Genetalia luar       : ......................................................................................................................
       Anus                     : ......................................................................................................................
       Pemeriksaan panggul (bila perlu) : ..............................................................................................
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3.    Pemeriksaan Penunjang                                                Tanggal : ..............., Jam ........... WIB
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I.    INTERPRETASI DATA
A.   Diagnosa Kebidanan
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B.   Masalah
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C.   Kebutuhan8
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III. IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL
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IV. ANTISIPASI TINDAKAN SEGERA
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V.   PERENCANAAN
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VI. PELAKSANAAN          Tanggal : ....................., Jam : ...............WIB, Oleh :.........................       ......................................................................................................................................................
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VII.EVALUASI                    Tanggal : ....................., Jam : ...............WIB.
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