Format Maternitas

FORMAT DOKUMENTASI
ASUHAN KEPERAWATAN MATERNITAS
_____________________________________________________________________
Disusun Oleh :
PRAKTIK PROFESI KEPERAWATAN MATERNITAS

PROGRAM STUDI PENDIDIKAN PROFESI NERS
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MALANG
TAHUN AKADEMIK 2018/2019
ASUHAN KEPERAWATAN PADA IBU HAMIL
Tanggal Kunjungan : ............................................................ Jam : ........................WIB

Ruang : ...............................................................................................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
IBU : ............................................... PENANGGUNG JAWAB
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Suku/Bangsa : ............................................... Suku/Bangsa : ....................................
Pendidikan : ............................................... Pendidikan : ....................................
Pekerjaan : ............................................... Pekerjaan : ....................................
Alamat : ............................................... Alamat : ....................................
2. Keluhan Utama :
………………………………………………………………………………………………………………
……………………………………………………………………………………………....
3. Riwayat Penyakit Sekarang :

………………………………………………………………………………………………………………
……………………………………………………………………………………………....
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4. Riwayat Menstruasi
 Menarche : .......................................................... th
 Siklus : .......................................................... hari, teratur/tidak
 Lama menstruasi : .......................................................... hari
 Banyaknya ganti pembalut : .......................................................... kali/hari
 Dismenorea/tidak : ..........................................................
5. Riwayat kehamilan, persalinan dan nifas yang lalu

Anak Tanggal U Jenis Tempat Komplikasi Bayi Nifas
Ke- Lahir/Umur K Persalinan Persalinan Penolong Bayi Ibu PB/BB Keadaan Keadaan laktasi
6. Riwayat Kehamilan Sekarang

 G P A
 HPHT : ...............................................................
 Usia Kehamilan : ...............................................................
 Kunjungan ANC: teratur/tidak, frekuensi: kali
 Tempat ANC : ...............................................................
 Obat yang biasa dikonsumsi selama hamil : ...............................................................
 Gerakan Janin : ................................. kali/hari
 Pergerakan janin pertama………….kali pada usia kehamilan……………
 Imunisasi Toxoid Tetanus sebanyak………kali yaitu:
TT 1 : ...............................................................
TT I : ...............................................................
 Tanda-tanda bahaya : ...............................................................
 Tanda-tanda persalinan : ...............................................................
7. Riwayat Kesehatan Sekarang/yang Lalu

 Jantung : .......................................................................................................
 Hipertensi : .......................................................................................................
 Diabetes Melitus : .......................................................................................................
 Ginjal : .......................................................................................................
 Asma : .......................................................................................................
 Hepatitis : .......................................................................................................
 Lain-lain : .......................................................................................................
8. Riwayat Operasi Abdomen/SC

 Tempat : .......................................................................................................
 Penolong :
 Tanggal : .......................................................................................................
9. Riwayat Penyakit Keluarga:

 Jantung : .................................................................................................
 Hipertensi : .................................................................................................
 Diabetes Melitus : .................................................................................................
 Hepatitis : .................................................................................................
 Asma : .................................................................................................
 Ginjal : .................................................................................................
 Riwayat bayi kembar : .................................................................................................
10. Riwayat KB
………………………………………………………………………………………………………………
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11. Riwayat Sosial Ekonomi & Psikologis

 Status Perkawinan : Kawin:………kali
 Lama menikah………….tahun
 Umur menikah pertama kali;……………..tahun
 Kehamilan ini direncanakan/Tidak direncanakan:
 Perasaan ibu dan keluarga terhadap kehamilan:
 Pengambilan keputusan dalam keluarga:
 Tempat dan petugas yang diinginkan untuk membantu persalinan:
 Tempat rujukan jika terjadi komplikasi:
 Persiapan menjelang persalinan:
12. ACTIVITY DAILY LIVING

a. Pola makan & minum
Frekuensi : ............................................................................ kali sehari
Jenis : ..................................................................................................
Porsi : ..................................................................................................
Keluhan/Pantangan : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
BAK………kali/hari, konsistensi…………….., warna………………….
BAB………kali/hari, warna………………….., lendir darah:……………
d. Personal Hygiene
Mandi : ....................................................... kali sehari
Ganti pakaian dan pakaian dalam : ....................................................... kali sehari
e. Aktifitas
Pekerjaan sehari-hari : .................................................................................................
Keluhan : .................................................................................................
Hubungan seksual : ........................................................................... kali/minggu
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum-minuman keras : ...........................................................................................
Konsumsi obat terlarang : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
Keadaan Umum : ........................................................................................................
Tingkat Kesadaran : ........................................................................................................
1. Tanda-tanda vital:
Tekanan darah : .................................................................. mmHg
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Respiras : .................................................................. kali/menit
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
Kenaikan BB selama hamil : .................................................................. kg
LILA : .................................................................. cm
2. Pemeriksaan Fisik
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Muka : cloasma: oedeme:
Hidung : polip:
Gigi dan mulut : ............................................................................................
3. Leher
Pembesaran kelenjar tyroid : ............................................................................................
4. Payudara
Bentuk simetris : ............................................................................................
Keadaan putting susu : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
5. Abdomen
Pembesaran perut sesuai dengan usia kehamilan/tidak
Linea nigra : ............................................................................................
Bekas luka/operasi : ............................................................................................
6. Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pembesaran Kelenjar bartholini
Pengeluaran pervaginam : ........................................................................................
Bekas luka/jahitan perineum : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
7. Tangan dan Kaki

Simetris/tidak : ............................................................................................
Odeme pada tungkai bawah : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
PALPASI
Payudara
Colostrum : .....................................................................................................................
Benjolan : .....................................................................................................................
Abdomen
TFU : .................................................................. cm
Leopold I : ...............................................................................
Leopold II : ...............................................................................
Leopold III : ...............................................................................
Leopold IV : ...............................................................................
Taksiran Berat Badan Janin ( TBJ ) : ...............................................................................
Kontraksi: kali/10mnt. Lama….detik, kuat/lemah, teratur/tidak
Kandung Kemih : ...............................................................................
AUSKULTASI
DJJ : ...............................................................................
Frekuensi : ..................................... kali/menit, teratur/tidak
Punctum maksimum : ...............................................................................
PEMERIKSAAN PANGGUL
Lingkar panggul : ...............................................................................................
Distansia cristarum : ...............................................................................................
Distansia spinarum : ...............................................................................................
Conjungata Bourdeloque : ...............................................................................................
PEMERIKSAAN DALAM
Atas indikasi:.................................... Pukul: ....................... Oleh:....................................
Dinding vagina : ..........................................................................................
Portio : ..........................................................................................
Pembukaan servik : ..........................................................................................
Konsistensi : ..........................................................................................
Ketuban : ..........................................................................................
Presentasi Fetus : ..........................................................................................
Posisi : ..........................................................................................
Penurunan Bagian Terendah : ..........................................................................................
PEMERIKSAAN PENUNJANG
A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
B. Laboratorium
C. Pemeriksaan lainnya
Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.
ANALISIS DATA
HARI/TGL : ...............................................................................................
NO DATA ETIOLOGI MASALAH

A. DIAGNOSA KEPERAWATAN
NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN
RENCANA TINDAKAN KEPERAWATAN
DIAGNOSA NAMA & TANDA

NO TUJUAN DAN KRITERIA HASIL RENCANA INTERVENSI
KEPERAWATAN TANGAN
IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN
NO TANGGAL JAM TINDAKAN KEPERAWATAN NAMA &

TANDA
TANGAN
B. EVALUASI
DIAGNOSA TANGGAL
N
KEPERAWA
O
TAN
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N DIAGNOSA TANGGAL
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KEPERAWA
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Mengetahui,
Preceptor Akademik Peceptor Lahan
(.......................................................) (……………………………….)
ASUHAN KEPERAWATAN PADA IBU BERSALIN
Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

Jam Masuk : .......................................... Jam Pengkajian : ....................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama Suami : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Utama Masuk Kamar Bersalin:
Menarche : .......................................................... th
Siklus : .......................................................... hari, teratur/tidak
Lama menstruasi : .......................................................... hari
Banyaknya ganti pembalut : .......................................................... kali/hari
Dismenorea/tidak : ..........................................................
4. Tanda-Tanda Persalinan
Kontraksi:........................... Sejak tanggal: ......................... Pukul: .........................
Frekuensi : ..........................................................
Lamanya:........................... kekuatannya ....................................
Lokasi ketidaknyamanan : ..........................................................
5. Pengeluaran Pervaginam
Darah lendir : ....................... Ada/tidak, Jumlah:............. Warna: .........................
Air Ketuban : ....................... Ada/tidak, Jumlah: ............ Warna: .........................
Darah : ....................... Ada/tidak, Jumlah:............. Warna:..........................


 G P A
HPHT : ...............................................................
Usia Kehamilan : ...............................................................
Tempat ANC : ...............................................................
Obat yang biasa dikonsumsi selama hamil : ...............................................................
Gerakan Janin : ................................. kali/hari
TT 1 : ...............................................................
TT I : ...............................................................
Tanda-tanda bahaya : ...............................................................
Tanda-tanda persalinan : ...............................................................

Jantung : .......................................................................................................
Hipertensi : .......................................................................................................
Diabetes Melitus : .......................................................................................................
Ginjal : .......................................................................................................
Asma : .......................................................................................................
Hepatitis : .......................................................................................................
Lain-lain : .......................................................................................................

Tempat : .......................................................................................................
Penolong : .......................................................................................................
Tanggal : .......................................................................................................

Jantung : .................................................................................................
Hipertensi : .................................................................................................
Diabetes Melitus : .................................................................................................
Hepatitis : .................................................................................................
Asma : .................................................................................................
Ginjal : .................................................................................................
Riwayat bayi kembar : .................................................................................................
11. Riwayat KB :
………………………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………………

 Kehamilan ini direncanakan/Tidak direncanakan
 Perasaan ibu dan keluarga terhadap kehamilan
 Pengambilan keputusan dalam keluarga…………….
 Tempat dan petugas yang diinginkan untuk membantu persalinan:
 Tempat rujukan jika terjadi komplikasi
 Persiapan menjelang persalinan

Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Aktifitas
Keluhan : .................................................................................................
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
Keadaan Umum : ........................................................................................................
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Respirasi : .................................................................. kali/menit
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Muka: cloasma: oedeme:
Hidung: polip:
Gigi dan mulut : ............................................................................................
3. Leher
4. Payudara
Bentuk simetris : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
5. Abdomen
Linea nigra : ............................................................................................
8. Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pengeluaran pervaginam : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
9. Tangan dan Kaki

Simetris/tidak : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
PALPASI
Payudara
Colostrum : .....................................................................................................................
Benjolan : .....................................................................................................................
Abdomen
TFU : .................................................................. cm
Leopold I : ...............................................................................
Leopold II : ...............................................................................
Leopold III : ...............................................................................
Leopold IV : ...............................................................................
Taksiran Berat Badan Janin ( TBJ ) : ...............................................................................
Kontraksi: kali/10mnt. Lama….detik, kuat/lemah, teratur/tidak
Kandung Kemih : ...............................................................................
AUSKULTASI
DJJ : ...............................................................................
Frekuensi : ..................................... kali/menit, teratur/tidak
Punctum maksimum : ...............................................................................
PEMERIKSAAN PANGGUL
Lingkar panggul : ...............................................................................................
Distansia cristarum : ...............................................................................................
Distansia spinarum : ...............................................................................................
Conjungata Bourdeloque : ...............................................................................................
PEMERIKSAAN DALAM
Atas indikasi:.................................... Pukul: ....................... Oleh:....................................
Dinding vagina : ..........................................................................................
Portio : ..........................................................................................
Pembukaan servik : ..........................................................................................
Konsistensi : ..........................................................................................
Ketuban : ..........................................................................................
Presentasi Fetus : ..........................................................................................
Posisi : ..........................................................................................
Penurunan Bagian Terendah : ..........................................................................................
Radiologi
Laboratorium
Pemeriksaan lainnya
Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.
KALA II
Subyektif :
Obyektif :
Assesment :
Planning :
KALA III
Subyektif :
Obyektif :
Assesment :
Planning :
KALA IV
Subyektif :
Obyektif :
Assesment :
Planning :
ANALISIS DATA
HARI/TGL : ...............................................................................................

DIAGNOSA KEPERAWATAN
NAMA & TANDA

TANGAN

KEPERAWATAN TANGAN

NAMA &
NO TANGGAL JAM TINDAKAN KEPERAWATAN TANDA
TANGAN
EVALUASI
DIAGNOSA TANGGAL
N
KEPERAWA
O
TAN
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...................
Mengetahui,
Pembimbing Akademik Pembimbing Lahan
(.......................................................) (……………………………….)
ASUHAN KEPERAWATAN PADA IBU NIFAS

Tempat : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Utama/Alasan Masuk:

………………………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………………
Menarche : .......................................................... th

Penolong
Ke- Lahir/Umur K Persalinan Persalinan Bayi Ibu PB/BB Keadaan Keadaan laktasi
5. Riwayat Persalinan Sekarang

Tanggal/Jam Persalinan : ...........................................................................................
Tempat Persalinan : ...........................................................................................
Penolong Persalinan : ...........................................................................................
Jenis Persalinan : ...........................................................................................
Komplikasi Persalinan : ...........................................................................................
Keadaan Plasenta : ...........................................................................................
Tali Pusat : ...........................................................................................
Lama Persalinan : Kala I ........ Kala II ......... Kala III ........... Kala IV ............
Jumlah Perdarahan : BB: ............ PB: ............. Apgar Score: .............
Bayi : BB: ............ PB: ............. Apgar Score: .............
Cacat Bawaan: ............... Cacat Bawaan: .................
Masa Gestasi: ................ minggu

 G P A
HPHT : ...............................................................
Usia Kehamilan : ...............................................................
Tempat ANC : ...............................................................
Obat yang biasa dikonsumsi selama hamil : ...............................................................
Gerakan Janin : ................................. kali/hari
TT 1 : ...............................................................
TT I : ...............................................................
Tanda-tanda bahaya : ...............................................................
Tanda-tanda persalinan : ...............................................................

Jantung : .......................................................................................................
Hipertensi : .......................................................................................................
Diabetes Melitus : .......................................................................................................
Ginjal : .......................................................................................................
Asma : .......................................................................................................
Hepatitis : .......................................................................................................
Lain-lain : .......................................................................................................

Tempat : .......................................................................................................
Penolong : .......................................................................................................
Tanggal : .......................................................................................................

Jantung : .................................................................................................
Hipertensi : .................................................................................................
Hepatitis : .................................................................................................
Asma : .................................................................................................
Ginjal : .................................................................................................
10. Riwayat KB
………………………………………………………………………………………………………………
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 Kehamilan ini direncanakan/Tidak direncanakan
 Perasaan ibu dan keluarga terhadap kehamilan
 Pengambilan keputusan dalam keluarga…………….
12. Riwayat Psikososial

Taking In : ..............................................................................................................
Taking Hold : ..............................................................................................................
Letting Go : ..............................................................................................................
Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Mobilisasi
……………………………………………………………………………………………………………
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f. Aktifitas
Keluhan : .................................................................................................
g. Menyusui
Keluhan : .................................................................................................
h. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
Keadaan Umum : ........................................................................................................
Tanda-tanda vital:
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Pemeriksaan Fisik
Inspeksi :
............................................................................................
Postur Tubuh :
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Kepala :
............................................................................................
Rambut :
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Mata: conjungtiva: sklera:
Hidung: polip:
Gigi dan mulut : ............................................................................................
Leher
Payudara
Bentuk simetris : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
Abdomen
Linea nigra : ............................................................................................
Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pengeluaran pervaginam : ..................................... Lochea: ................................
Bau : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
Tangan dan Kaki

Simetris/tidak : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
A. Radiologi
B. Laboratorium
C. Pemeriksaan lainnya
Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.
ANALISIS DATA
HARI/TGL : ...............................................................................................
NO TANGGAL DIAGNOSA KEPERAWATAN NAMA & TANDA

TANGAN

KEPERAWATAN TANGAN
Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 35

NAMA &
TANGAN
EVALUASI

DIAGNOSA TANGGAL
N
KEPERAWA
O
TAN
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N DIAGNOSA TANGGAL
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Mengetahui,
(.......................................................) (……………………………….)

ASUHAN KEPERAWATAN PADA BAYI BARU LAHIR

Tempat : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Identitas Pasien
PASIEN : .............................................. PENANGGUNG JAWAB
Nama : .............................................. Nama : ....................................
Umur : .............................................. Umur : ....................................
Tgl./Jam Lahir : .............................................. Agama : ....................................
Jenis Kelamin : .............................................. Suku/Bangsa : ....................................
BB Lahir : .............................................. Pendidikan : ....................................
Panjang Badan : .............................................. Pekerjaan : ....................................
.............................................. Alamat : ....................................
2. Riwayat Kesehatan Ibu

Jantung : ..................................................................................................
Hipertensi : ..................................................................................................
Diabetes Melitus : ..................................................................................................
Ginjal : ..................................................................................................
Asma : ..................................................................................................
Hepatitis : ..................................................................................................
Riwayat Operasi/SC : ..................................................................................................
3. Riwayat Penyakit Keluarga

Jantung : ...............................................................................................
Hipertensi : ...............................................................................................
Diabetes Melitus : ...............................................................................................
Hepatitis : ...............................................................................................
Asma : ...............................................................................................
Ginjal : ...............................................................................................
Riwayat Bayi Kembar : ...............................................................................................
4. Riwayat Persalinan Sekarang

 G P A
Usia Kehamilan :
Tanggal/Jam Persalinan : ...........................................................................................
Tempat Persalinan : ...........................................................................................
Penolong Persalinan : ...........................................................................................
Jenis Persalinan : ...........................................................................................
Komplikasi Persalinan : ...........................................................................................
Pada Ibu : ...........................................................................................

Pada Bayi : ...........................................................................................
Ketuban Pecah : ...........................................................................................
Keadaan Plasenta : ...........................................................................................
Tali Pusat : ...........................................................................................
Lama Persalinan : Kala I ........ Kala II ......... Kala III ........... Kala IV ............
Jumlah Perdarahan : BB: ............ PB: ............. Apgar Score: .............
Selama Operasi : ...........................................................................................
5. Riwayat Kehamilan
Riwayat Komplikasi Kehamilan
Perdarahan : ...............................................................................................
Preeklampsi/Eklampsi : ...............................................................................................
Penyakit Kelamin : ...............................................................................................
Lain-Lain : ...............................................................................................
Kebiasaan Ibu Waktu Hamil
Makanan : ...............................................................................................
Obat-Obatan : ...............................................................................................
Jamu : ...............................................................................................
Merokok : ...............................................................................................
B. Data Objektif
1. Kebutuhan Bayi
Intake : ..................................................................................................
Eliminasi : ..................................................................................................
Miksi : ..................................................................................................
Keluar Tanggal : ..................................................................................................
Mekonium : ..................................................................................................
Warna : ..................................................................................................
Keluar Tanggal : ..................................................................................................
Aktifitas : ..................................................................................................
2. Antropometri
Berat Badan : ..................................................................................................
Panjang Badan : ..................................................................................................
Lingkar Kepala : ..................................................................................................
Lingkar Dada : ..................................................................................................
Lingkar perut : ..................................................................................................
3. Pemeriksaan Umum
Jenis kelamin : ...............................................................................................
APGAR Score : ...............................................................................................
Keadaan Umum Bayi : ...............................................................................................
Suhu : ...............................................................................................
Bunyi jantung : ...............................................................................................
Frekuensi : ...............................................................................................
Respirasi : ...............................................................................................

Kepala
Fontanel anterior : ............................................................................................
Sutura sagitalis : ............................................................................................
Caput succedanum : ............................................................................................
Cepal hematom : ............................................................................................
Mata
Letak : ............................................................................................
Bentuk : ............................................................................................
Sekret : ............................................................................................
Conjungtiva : ............................................................................................
Sklera : ............................................................................................
Hidung
Bentuk : ............................................................................................
Sekret : ............................................................................................
Mulut
Bibir : ............................................................................................
Palatum : ............................................................................................
Telinga
Bentuk : ............................................................................................
Simetris : ............................................................................................
Sekret : ............................................................................................
Leher
Pergerakan : ............................................................................................
Pembengkakan : ............................................................................................
Kekakuan : ............................................................................................
Dada
Bentuk : ............................................................................................
Retrksi dinding dada : ............................................................................................
Paru-paru
Suara nafas : ............................................................................................
Respirasi : ............................................................................................
Abdomen
Peristaltik usus : ............................................................................................
Tali pusat : ............................................................................................
Punggung
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Tangan dan Kaki
Gerakan : ............................................................................................
Bentuk : ............................................................................................
Jumlah : ............................................................................................
Warna : ............................................................................................
Reflek
Reflek moro : ............................................................................................
Reflek rooting : ............................................................................................
Reflek sucking : ............................................................................................
Reflek walking : ............................................................................................
Reflek tonic neck : ............................................................................................
Reflek babinski : ............................................................................................
Reflek graping : ............................................................................................
Pemeriksaan Penunjang
Radiologi
Laboratorium

Pemeriksaan lainnya
Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.

ANALISIS DATA
HARI/TGL : ...............................................................................................
NO TANGGAL DIAGNOSA KEPERAWATAN NAMA & TANDA

TANGAN


KEPERAWATAN TANGAN
NAMA &
TANGAN
EVALUASI

DIAGNOSA TANGGAL
N
KEPERAWA
O
TAN
S: ............................................... S: S: ...............................................
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Mengetahui,
(.......................................................) (……………………………….)

ASUHAN KEPERAWATAN PADA AKSEPTOR KB……
Tanggal Kunjungan : .......................................... Jam : .................................. WIB

Ruang : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Kunjungan
………………………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………………
Menarche : .......................................................... th

5. Riwayat Kesehatan/Penyakit Sekarang/yang Lalu

Jantung : ..................................................................................
Hipertensi : ..................................................................................
Diabetes Melitus : ..................................................................................
Ginjal : ..................................................................................
Asma : ..................................................................................
Hepatitis : ..................................................................................
HIV/AIDS : ..................................................................................
Riwayat Operasi Abdomen/SC : ..................................................................................

Jantung : .................................................................................................
Hipertensi : .................................................................................................
Hepatitis : .................................................................................................
Asma : .................................................................................................
Ginjal : .................................................................................................
7. Riwayat KB
………………………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………………

 Respon Ibu/Suami terhadap pemakaian
 Pengambilan keputusan dalam keluarga alat kontrasepsi

Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Aktifitas
Keluhan : .................................................................................................
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................

B. Data Objektif
Keadaan Umum : ........................................................................................................
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Hidung: polip:
Gigi dan mulut : ............................................................................................
3. Leher
4. Payudara
Bentuk simetris : ............................................................................................
Ada Benjolan atau Tidak : ............................................................................................
5. Abdomen
Inspeksi : ............................................................................................
Palpasi : ............................................................................................
6. Genetalia
Varises : ........................................................................................
7. Anus
Heaemoroid/tidak : ........................................................................................
8. Ekstremitas (Tangan dan Kaki)

Simetris/tidak : ........................................................................................
Oedeme pada Tungkai Bawah : ........................................................................................
Varises : ........................................................................................
Pergerakan : ........................................................................................
9. Pemeriksaan Penunjang

D. Radiologi
E. Laboratorium
F. Pemeriksaan lainnya

Mengetahui, ...............................,......................................
Pembimbing klinik .
Mahasiswa
(.......................................................)
(............................................................)
NIM.
ANALISIS DATA
HARI/TGL : ...............................................................................................

NAMA & TANDA

TANGAN


KEPERAWATAN TANGAN

NAMA &
TANGAN

EVALUASI
DIAGNOSA TANGGAL
N
KEPERAW
O
ATAN
S: ........................................... S: S: ............................................
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Mengetahui,
(.......................................................) (……………………………….)

FORMAT PENGKAJIAN GANGGUAN REPRODUKSI
Askep : ..............................................................................................................
: ..............................................................................................................
Tanggal Pengkajian : ..............................................................................................................
Ruang/RS : ..............................................................................................................
A. DATA UMUM KLIEN

Nama Klien : .................................................................................................
Usia : .................................................................................................
Agama : .................................................................................................
Status perkawinan : .................................................................................................
Pekerjaan : .................................................................................................
Pendidikan Terakhir : .................................................................................................
Nama suami : .................................................................................................
Umur : .................................................................................................
Agama : .................................................................................................
Pekerjaan : .................................................................................................
Pendidikan terakhir : .................................................................................................
Alamat : .................................................................................................
B. ANAMNESE
Diagnosa Medis : ....................................................................................
Keluhan Utama : ....................................................................................
Keluhan Saat pengkajian : ....................................................................................
Riwayat penyakit Sekarang : ....................................................................................
Riwayat penyakit yang lalu : ....................................................................................
Riwayat kesehatan keluarga : ....................................................................................
Riwayat menstruasi
Menarche : ..................................... Umur: ..................... th
Siklus : ...............................................................................................
Jumlah : ...............................................................................................
Lamanya : ...............................................................................................
Keteraturan : ...............................................................................................
Dsmenorhea : ...............................................................................................
Masalah Khusus : ...............................................................................................
Riwayat Perkawinan
Status perkawinan : ..............................................................................................
Dengan suami : ..............................................................................................
Lama perkawinan : ..............................................................................................
Riwayat KB : ....................................................................................
Pola Aktifitas sehari-hari
Makan dan minum : ........................................................................................
Pola eliminasi : ........................................................................................
Pola istirahat dan tidur : ........................................................................................
Kebersihan diri : ........................................................................................
Riwayat Psikososial : ....................................................................................
C. PEMERIKSAAN FISIK
Keadaan Umum : ...............................................................................
Tanda vital : ...............................................................................
Pemeriksaan Kepala dan leher : ...............................................................................
Dada dan thorax : ...............................................................................
Payudara : ...............................................................................
Abdomen : ...............................................................................
Genetalia : ...............................................................................
Extremitas : ...............................................................................

Pemeriksaan neurologis : ...............................................................................
Pemeriksaan Penunjang : ...............................................................................
Terapi/penatalaksanaan : ...............................................................................
D. ANALISA DATA
E. DIAGNOSA KEPERAWATAN
F. RENCANA KEPERAWATAN
G. IMPLEMENTASI KEPERAWATAN
H. EVALUASI
I. CATATAN PERKEMBANGAN

FORMAT LAPORAN PENDAHULUAN
__________________________________________________________________
Disusun Oleh :


FORMAT LAPORAN PENDAHULUAN
I. DEFINISI
II. PATOFISIOLOGI (POHON MASALAH)
III. ETIOLOGI

IV. GEJALA/ TANDA
V. MASALAH KEPERAWATAN
VI. PEMERIKSAAN PENUNJANG

Pemeriksaan Diagnostik Hasil
1. ………………………………………………… 1. …………………………………………………
2. ………………………………………………… 2. …………………………………………………
3. ………………………………………………… 3. …………………………………………………
VII. PENATALAKSANAAN
a. Penatalaksanan Medis
b. Penatalaksanaan Keperawatan :

VIII. ASUHAN KEPERAWATAN
a. Pengkajian Fokus (sesuai kasus)
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b. Diagnosa yang mungkin muncul

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c. Rencana Keperawatan
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Mahasiswa
(..............................................)
NIM:.....................................
FORMAT LAPORAN RESUME
_____________________________________________________________________

Disusun Oleh :


FORMAT RESUME KEPERAWATAN
KASUS :…………………………………….
A. Pengertian/Definisi :
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B. Etiologi :
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C. Pengkajian
 Identitas :
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 Riwayat :
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 Pemeriksaan Fisik :
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 Pemeriksaan Diagnostik :
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b. Masalah Keperawatan/ Diagnosa Keperawatan :
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c. Penatalaksanaan Terapi/ Implementasi
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d. Evaluasi :
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Mahasiswa
(..............................................)
NIM:.....................................

DAFTAR KEHADIRAN MAHASISWA
NAMA MAHASISWA : ........................................................................................................................................
NIM : ........................................................................................................................................
KELOMPOK : .........................................................................................................................................
No. Nama Hari/ Tanggal

Ruangan
Senin,………… Selasa,…………….. Rabu,…………… Kamis,………….. Jumat,……………. Sabtu,…………….
Pkl……. Pkl…… Pkl……. Pkl…… Pkl…… Pkl……. Pkl…… Pkl……. Pkl……. Pkl……. Pkl……. Pkl…….
1. Tanda
Tangan
Clinical
Instruktur
2. Catatan
Clinical
Instruktur
JADWAL PRAKTIK PROFESI KEPERAWATAN MATERNITAS

MAHASISWA PROGRAM STUDI PENDIDIKAN NERS POLTEKKES KEMENKES MALANG
SEMESTER I TAHUN AKADEMIK 2018/2019
MINGGU
KELOMPOK 5 6 10 11 12 15 16 17 15 16 17 18
7 8 9 13 14 18
17-22 24-29 22-27 29 Okt- 05-10 26 Nov-01 03-08 10-15 24 Des – 31 Des – 7- 12 14 –
01-06 Okt 08-13 Okt 15-20 Okt 12-17 Nov 19-24 Nov 17-22 Des
Sept Sept Okt 03 Nov Nov Des Des Des 29 Des 5 Jan Jan 19 Jan
Kelompok 1 KDP KDP KMB KMB Anak Anak Anak Anak Poli Obgyn R. Puskesmas Jiwa Jiwa Jiwa KMB KMB KMB KMB
1. Avrizal Falefi R. Topaz 1 R. Topaz 1 R.13 R.29 R.11 R.15 R.7a R.7b RSUD Wlingi Obgyn/Kab Wagir RSJ RSJ RSJ R.16 R.26s R.19 R.5
2. Adila Alif RS RS RSSA RSSA RSSA RSSA RSSA RSSA (Sri M.) er (Sumirah Lawang Lawang Lawang RSSA RSSA RSSA RSSA
Nugrahaeni Lavalette Lavalette RSUD B.P)
3. Siti Arwani Wlingi
4. Deva Resti (G.M
Anggraini Sindarti)
Kelompok 2 KDP KDP KMB KMB Anak Anak Anak Anak R. Puskesmas Poli Obgyn Jiwa Jiwa Jiwa KMB KMB KMB KMB
1. Rezky Alfian R.Topaz 2 R.Topaz 2 R.29 R.16 R.7b R.11 R.15 R.7a Obgyn/Kaber Wagir RSUD Wlingi RSJ RSJ RSJ R.19 R.5 R.13 R.26s
Maliq RS RS RSSA RSSA RSSA RSSA RSSA RSSA RSUD Wlingi (Tutik H.) (Ririn A.) Lawang Lawang Lawang RSSA RSSA RSSA RSSA
2. Fita Lavalette Lavalette (Sri M.)
Purnamasari
Rahmadhani
3. Khusnatul
Maghfiroh
4. Rosyada
Nirmala
Kelompok 3 KDP KDP KMB KMB Anak Anak Anak Anak Puskesmas Poli Obgyn R. Jiwa Jiwa Jiwa KMB KMB KMB KMB
1. Iqlima Alvein R. R. Diamond R.16 R.13 R.7a R.7b R.11 R.15 Wagir RSUD Obgyn/Kaber RSJ RSJ RSJ R.29 R.19 R.5 R.26i
Nafiisah Diamond RS RSSA RSSA RSSA RSSA RSSA RSSA (Fitriana K.S) Wlingi RSUD Wlingi Lawang Lawang Lawang RSSA RSSA RSSA RSSA
2. Bagas Rani RS Lavalette (G.M (Ririn A.)
Putra Lavalette Sindarti)
Pradana
3. Rachmatul
Hasanah
4. Ardika

MINGGU
KELOMPOK 5 6 10 11 12 15 16 17 15 16 17 18
7 8 9 13 14 18
17-22 24-29 22-27 29 Okt- 05-10 26 Nov-01 03-08 10-15 24 Des – 31 Des – 7- 12 14 –
Sulisetiyani
Kelompok 4 KDP KDP Poli Obgyn Puskesmas R. Obgyn Jiwa Jiwa Jiwa KMB KMB KMB KMB KMB KMB Anak Anak Anak Anak
1. Daniar Ade R. Zamrud R. Zamrud RSUD Wagir RSUD RSJ RSJ RSJ R.23i R.17 R.19 R.16 R.26i R.29 R.11 R.HCU R.7b R.15
Setiawan RS RS Wlingi (Ririn A.) Wlingi Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA
2. Winda Yunita Lavalette Lavalette (Sumirah (Ririn A.)
Miftahul B.P)
Jannah
3. Fajrian Dwi
Anggraeni
4. Dewi Retno
Wulandari
Kelompok 5 KDP KDP R. Obgyn Poli Obgyn Puskesmas Jiwa Jiwa Jiwa KMB KMB KMB KMB KMB KMB Anak Anak Anak Anak
1. Rifandi R. Rubi R. Rubi RSUD RSUD Wagir RSJ RSJ RSJ R.17 R.23i R.16 R.26i R.29 R.5 R.15 R.11 R.HCU R.7b
Handrianto RS RS Wlingi Wlingi (Tutik H.) Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA
2. Ahmad Lavalette Lavalette (Sri M.) (Fitriana
Hendi K.S)
Herdianto
3. Agni Ayu
Murbarani
4. Wahyu
Jauhar N.
Kelompok 6 KDP KDP R. Kaber R. Kaber Poli Obgyn Jiwa Jiwa Jiwa KMB KMB KMB KMB KMB KMB Anak Anak Anak Anak
1. Alkhalifa R. R. RSUD RSUD RSUD RSJ RSJ RSJ R.19 R.16 R.17 R.29 R.5 R.26i R.7b R.15 R.11 R.HCU
Amin Flamboyan Flamboyan Wlingi Wlingi Wlingi Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA
2. Ferensa RST RST (Sri M.) (G.M (Ririn A.)
Yulinda Sindarti)
Rastra Putri
3. Anggina Ayu
Dhewanty
4. Luluk
Mamluatul U.
MINGGU
KELOMPOK 5 6 10 11 12 15 16 17 15 16 17 18
7 8 9 13 14 18
17-22 24-29 22-27 29 Okt- 05-10 26 Nov-01 03-08 10-15 24 Des – 31 Des – 7- 12 14 –
Kelompok 7 KDP KDP Puskesmas R. Obgyn R. Kaber Jiwa Jiwa Jiwa KMB KMB KMB KMB KMB KMB Anak Anak Anak Anak
1. Bima Ragil R. R. Wagir RSUD RSUD RSJ RSJ RSJ R.5 R.26s R.23i R.17 R.19 R.16 R.HCU R.7b R.15 R.11
Pranata Cempaka Cempaka (Fitriana Wlingi Wlingi Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA
2. Yaomil Dayu RST RST K.S) (Fitriana (Sumirah
Satriyani K.S) B.P)
3. Rizky Nurlaili
4. Zahraul
Mufidah
Kelompok 8 KDP KDP Jiwa Jiwa Jiwa KMB KMB KMB KMB Anak Anak Anak Anak Poli Obgyn Puskesmas R. Obgyn KMB KMB
1. Martoyo R. Teratai R. Teratai RSJ RSJ RSJ R.16 R.29 R.17 R.26i R.11 R.HCU R.7b R.15 RSUD Wagir RSUD R.13 R.23i
Ichwan RST RST Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA Wlingi (Sri M) Wlingi RSSA RSSA
2. Ni Putu (Sri M) (Sumirah
Ardiyani B.P)
3. Dian Widhi
Pawestri
4. Rifta
Elmaviana
Kelompok 9 KDP KDP Jiwa Jiwa Jiwa KMB KMB KMB KMB Anak Anak Anak Anak R. Obgyn Poli Obgyn Puskesmas KMB KMB
1. Melkias R. R. Kenanga RSJ RSJ RSJ R.29 R.16 R.19 R.26s R.15 R.11 R.HCU R.7b RSUD RSUD Wagir R.26i R.13
Melatunan Kenanga RST Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA Wlingi Wlingi (Tutik) RSSA RSSA
2. Ni Putu Devi RST (Sri M.) (Fitriana
Indriyani K.S)
3. Audina Zefa
Fabela
Kelompok 10 KDP KDP Jiwa Jiwa Jiwa KMB KMB KMB KMB Anak Anak Anak Anak R. Kaber R. Kaber Poli Obgyn KMB KMB
1. M Ilham R. Seruni R. Seruni RSJ RSJ RSJ R.17 R.13 R.5 R.16 R.7b R.15 R.11 R.HCU RSUD RSUD RSUD R.29 R.19
Santoso RST RST Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA RSSA RSSA RSSA Wlingi Wlingi Wlingi RSSA RSSA
2. Tyas Hanif (Fitriana (G.M (Ririn A.)
Muslimah K.S) Sindarti)
3. Siti Rizki
Amalia
Kelompok 11 KDP KDP Jiwa Jiwa Jiwa KMB KMB KMB KMB Anak
MINGGU
KELOMPOK 5 6 10 11 12 15 16 17 15 16 17 18
7 8 9 13 14 18
17-22 24-29 22-27 29 Okt- 05-10 26 Nov-01 03-08 10-15 24 Des – 31 Des – 7- 12 14 –
1. Dhian Ndaru R. Dahlia R. Dahlia RSJ RSJ RSJ R.13 R.17 R.16 R.26p R.HCU
Aryanto RST RST Lawang Lawang Lawang RSSA RSSA RSSA RSSA RSSA
2. Arina
Hidayati
3. Bryna Zara
Vania
Malang, 15 Januari 2018
Ketua Program Studi Pendidikan Profesi Ners
Joko Wiyono, S.Kp., M.Kep., Sp.Kom
NIP. 1969009021992031002

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FORMAT DOKUMENTASI

ASUHAN KEPERAWATAN MATERNITAS

PRAKTIK PROFESI KEPERAWATAN MATERNITAS

Tanggal Kunjungan : ............................................................ Jam : ........................WIB

3. Riwayat Penyakit Sekarang :

5. Riwayat kehamilan, persalinan dan nifas yang lalu

6. Riwayat Kehamilan Sekarang

7. Riwayat Kesehatan Sekarang/yang Lalu

8. Riwayat Operasi Abdomen/SC

9. Riwayat Penyakit Keluarga:

11. Riwayat Sosial Ekonomi & Psikologis

12. ACTIVITY DAILY LIVING

7. Tangan dan Kaki

NO DATA ETIOLOGI MASALAH

NAMA & TANDA

DIAGNOSA NAMA & TANDA

IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NO TANGGAL JAM TINDAKAN KEPERAWATAN NAMA &

Preceptor Akademik Peceptor Lahan

ASUHAN KEPERAWATAN PADA IBU BERSALIN

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Alasan Utama Masuk Kamar Bersalin:

6. Riwayat kehamilan, persalinan dan nifas yang lalu

7. Riwayat Kehamilan Sekarang

8. Riwayat Kesehatan Sekarang/yang Lalu

9. Riwayat Operasi Abdomen/SC

10. Riwayat Penyakit Keluarga:

12. Riwayat Sosial Ekonomi & Psikologis

13. ACTIVITY DAILY LIVING

9. Tangan dan Kaki

NO DATA ETIOLOGI MASALAH

NAMA & TANDA

DIAGNOSA NAMA & TANDA

IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

ASUHAN KEPERAWATAN PADA IBU NIFAS

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Alasan Utama/Alasan Masuk:

4. Riwayat kehamilan, persalinan dan nifas yang lalu

5. Riwayat Persalinan Sekarang

6. Riwayat Kehamilan Sekarang

7. Riwayat Kesehatan Sekarang/yang Lalu

8. Riwayat Operasi Abdomen/SC

9. Riwayat Penyakit Keluarga:

12. Riwayat Psikososial

Tangan dan Kaki

NO DATA ETIOLOGI MASALAH

NO TANGGAL DIAGNOSA KEPERAWATAN NAMA & TANDA

DIAGNOSA NAMA & TANDA

IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 35

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 36

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 37

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 38

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Riwayat Kesehatan Ibu

3. Riwayat Penyakit Keluarga

4. Riwayat Persalinan Sekarang

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 39

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 40

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 41

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 42

Proposal Praktik Keperawatan Maternitas Prodi Profesi Ners Semester I TA 2018/2019 43

NO DATA ETIOLOGI MASALAH