LAPORAN KASUS

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PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS KEDOKTERAN UNIVERSITAS ANJUNGPURA
TAHUN 2016

LEMBAR PENGESAHAN
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Tanggal ................................

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NIM ...............................

Mengetahui,

Singkawang, ................ 20.....

Penguji Pendidikan

Penguji Lahan

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FORMAT PENGKAJIAN ANTENATAL CARE

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk
: ........................................
Ruang/kelas
: ........................................
Pengkajian tanggal : ........................................

I. IDENTITAS
Nama pasien
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Alamat

:
:
:
:
:
:
:

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

Jam masuk
Kamar no.
Jam pengkajian

: ........................................
: ........................................
: ........................................

Nama suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Alamat

:
:
:
:
:
:
:

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

II. KELUHAN UTAMA / ALASAN KUNJUNGAN

...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
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...............................................................................................................................................................
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III. RIWAYAT KEBIDANAN
1. Riwayat Perkawinan
Status perkawinan : kawin : ( ) ya ( ) tidak
Jika kawin
: berapa kali : lamanya :
2. Riwayat Haid
Menarche umur
Haid
Dismenore
Warna
Bentuk haid
Bau haid
Fluor albus
Kapan
Banyaknya
Lama
Warna
Bau

usia :

: tahun
: teratur : ( ) ya ( ) tidak
siklus : hari
: ( ) ya
( ) tidak
: ( ) merah tua
( ) merah segar
( ) merah kehitaman
( ) coklat
: ( ) cair/encer
( ) bergumpal
( ) flek
: ( ) anyir
( ) busuk
: ( ) ya
( ) tidak
: ( ) sebelum haid
( ) sesudah haid
: ( ) banyak
( ) sedikit
:
:
:

3. Riwayat Kehamilan, Nifas dan Anak yang Lalu

Anak ke
Kehamilan
Persalinan
No.

Tahun

Umur kehamilan

Penyulit

Jenis

Penolong

Penyulit

Komplikasi nifas
Laserasi

Infeksi

Perdarahan

Anak
Jenis

BB

IV. RIWAYAT KEHAMILAN SEKARANG

1. HPHT (hamil berapa bulan)
: .......................................................................................
2. Gerakan janin
: .......................................................................................
3. Tanda-tanda bahaya/penyulit
: .......................................................................................
4. Keluhan umum
: .......................................................................................
5. Obat-obatan/jamu yang dikonsumsi
: .......................................................................................
6. Kekhawatiran khusus
: .......................................................................................
V. RIWAYAT KESEHATAN KELUARGA
1. Keturunan kembar
: ( ) ya ( ) tidak
2. Penyakit menular/keturunan
:
( ) diabetes mellitus
( ) hepatitis
( ) PJK
( ) tifoid
( ) hipertensi
( ) TB
( ) lain-lain, jelaskan .................................................................................................................
3. Genogram

VI. RIWAYAT KESEHATAN YANG LALU

Penyakit menular/keturunan :
( ) diabetes mellitus
( ) hepatitis
( ) PJK
( ) tifoid
( ) hipertensi
( ) TB
( ) lain-lain, jelaskan .......................................................................................................................
VII. RIWAYAT PSIKOSOSIAL SPIRITUAL
1. Komunikasi
a. Non verbal : ( ) lancar
( ) gugup
( ) afasia
b. Verbal
: ( ) bahasa Indonesia
( ) daerah
( ) lain-lain, jelaskan ...................................................................................

PJ

2. Keadaan emosional
( ) kooperatif
( ) depresi
( ) agresif
( ) hipoaktif
( ) bingung
( ) menarik diri
( ) cemas
( ) marah
( ) hiperaktif
( ) gelisah
3. Hubungan dengan keluarga
( ) akrab
( ) biasa
( ) terganggu
4. Hubungan dengan orang lain
( ) akrab
( ) biasa
( ) terganggu
5. Proses berpikir
( ) terarah
( ) bingung
( ) ilusi
( ) halusinasi
6. Ibadah/spiritual
( ) patuh
( ) tidak patuh
7. Respons ibu dan keluarga terhadap kehamilan : ............................................................................
8. Dukungan keluarga : .......................................................................................................................
9. Pengambilan keputusan dalam keluarga : ......................................................................................
10. Beban kerja dan kegiatan sehari-hari : ...........................................................................................
11. Tempat dan petugas yang diinginkan untuk bersalin : ...................................................................
VIII. PEMERIKASAAN
1. Keadaan umum
( ) lemah
2. Tanda vital
a. Suhu
b. Nadi
c. Pernapasan

d. Tekanan darah
e.
f.

Berat badan
Tinggi badan

3. Kepala
a. Wajah
b. Rambut
c.
d.
e.
f.
g.
h.
i.
j.
k.

) baik

: C
: x/menit
: x/menit
( ) teratur
( ) dalam
: mmHg
( ) berbaring
: kg
: cm

) cukup

(
(

) aksila
) teratur

(
(

(
(

) tidak teratur
) dangkal

) duduk

) oral
) tidak teratur

) rektal

) berdiri

: ( ) pucat
( ) sianosis
: kebersihan :
rontok
: ( ) ya
( ) tidak
Cloasma gravidarum : ( ) ada
( ) tidak ada
Pupil
: ( ) isokor ( ) anisokor
( ) miosis ( ) midriasis
Reaksi cahaya
: ( ) positif ( ) negatif
Konjungtiva
: ( ) pucat
( ) merah muda
( ) hiperemi
Sklera
: ( ) putih
( ) ikterus
( ) perdarahan
Mulut dan gigi
: ( ) karies ( ) stomatitis
( ) trismus ( ) perdarahan gusi
Lidah
: ( ) bersih ( ) kotor
Telinga
: ( ) serumen ( ) perdarahan
Lain-lain, jelaskan ...................................................................................................................

4. Leher
( ) pembesaran kelenjar tiroid
( ) pembesaran vena jugularis
( ) pembesaran kelenjar limfe
( ) lain-lain, jelaskan .................................................................................................................
5. Dada
a. Tarikan
b. Bentuk
c. Auskultasi paru
d. Auskultasi jantung
e. Mamae
f. Puting susu

:
:
:
:
:
:

(
(
(
(
(
(
(
(
g. Kolostrum
:(
h. Pembesaran mamae : (

)
)
)
)
)
)
)
)
)
)

ada
( ) tidak
simetris
( ) asimetris
vesikuler
( ) wheezing
s1s2 tunggal ( ) murmur
radang
( ) ada benjolan
menonjol
( ) datar
bersih
( ) kotor
hiperpigmentasi areola/papila
keluar
( ) belum
simetris
( ) asimetris

(
(
(
(

)
)
)
)

ronkhi
gallop
tidak ada benjolan
masuk

6. Abdomen
a. Inspeksi
Linea
: ( ) nigra
( ) alba
Striae
: ( ) albicans ( ) lividae
Bekas luka operasi : ( ) ada
( ) tidak ada
b. Pembesaran
: ( ) memanjang
( ) melintang
c. Terlihat gerak anak : ( ) ya
( ) tidak
d. Palpasi
TFU
: ..........................................................................................................................
Massa lain : ..........................................................................................................................
Leopold I : ..........................................................................................................................
Leopold II : ..........................................................................................................................
Leopold III : ..........................................................................................................................
Leopold IV : ..........................................................................................................................
e. Perkusi
: ( ) sonor
( ) redup ( ) timpani
f. Auskultasi
DJJ
: ( ) negatif
( ) positif x/menit
( ) teratur
( ) tidak teratur
Bising usus : ( ) negatif
( ) positif
( ) menurun ( ) meningkat
7. Panggul
a. Distancia spinarum
b. Distancia cristarum
c. Conjungata external
d. Lingkaran pinggul
8. Genitourinaria
( ) inkontinensia
( ) poliuria
( ) terpasang kateter

: .......................... cm
: .......................... cm
: .......................... cm
: .......................... cm

(
(
(

) retensio urine
) hematuria
) kandung kemih penuh

) disuria

9. Vulva/vagina
a. Kebersihan vulva

: ( ) bersih
( ) kotor
( ) varises
( ) hematoma
( ) fluxus
( ) fluor albus
( ) bau
( ) luka
b. Portio
: ( ) tertutup
( ) terbuka
( ) licin
( ) berdungkul
( ) nyeri goyang
( ) perdarahan
c. Uteri
: ( ) normal
( ) anteflexi
( ) retaflexi
( ) pembesaran
d. Adnexa
: ( ) nyeri tekan
( ) kanan
( ) kiri
( ) massa
e. Ukuran panggul dalam : cm
f. Cavum douglas
: ( ) tonjolan
( ) darah
g. Lain-lain, jelaskan
: .......................................................................................................

10. Ekstremitas atas dan bawah

( ) edema
( ) varises
( ) plegia
( ) parese
Refleks patela : .............................................................................................................................
Bentuk kaki
: .............................................................................................................................
11. Lain-lain, jelaskan ..........................................................................................................................
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12. Pemeriksaan penunjang
a. Laboratorium
b. USG
c. Rontgen
d. Terapi yang didapat

:
:
:
:

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IX. DATA TAMBAHAN

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Singkawang .....................
Pemeriksa

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

ANALISA DATA
Nama klien
Umur
No.

: ..............................................
: ..............................................
Data (Symptom)

Ruangan/kamar : ..............................................
No. RM
: ..............................................

Penyebab (Etiologi)

Masalah (Problem)

PRIORITAS MASALAH
Nama klien
Umur
No.

: ..............................................
: ..............................................
Masalah Keperawatan

Ruangan/kamar : ..............................................
No. RM
: ..............................................
Tanggal

Ditemukan

Teratasi

Paraf
(nama perawat)

RENCANA KEPERAWATAN
No.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT