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FORMAT ASUHAN KEPERAWATAN MATERNITAS

ANTE NATAL CARE (PRE-NATAL)

ASUHAN KEPERAWATAN ......................................................


DI RS. …………………………………

Disusun untuk memenuhi tugas PKK Keperawatan Kegawat Daruratan


Prodi D-III Keperawatan Fakultas Vokasi Universitas Airlangga

Oleh:

NAMA : Nurmarike Ismala Putri


NIM 151611913199

PRODI D-III KEPERAWATAN FAKULTAS VOKASI


UNIVERSITAS AIRLANGGA
2018
Mahasiswa : ……………………… Tanggal Pengkajian : …………….............
NIM : ……………………… Ruangan : …………….............

FORMAT ASUHAN KEPERAWATAN


ANTE NATAL CARE (PRE-NATAL)

PENGKAJIAN

Waktu MRS : …………………………………………………………………….


Ruangan : …………………………………………………………………….
Kamar No. : …………………………………………………………………….
No. RM : …………………………………………………………………….
Dx. Medis : …………………………………………………………………….

I. IDENTITAS KLIEN PENANGGUNG JAWAB


Nama : ………………….. Nama : …………………..
Umur : ………………….. Umur : …………………..
Suku : ………………….. Suku : …………………..
Bangsa : ………………….. Bangsa : …………………..
Pendidikan : ………………….. Pendidikan : …………………..
Pekerjaan : ………………….. Pekerjaan : …………………..
Alamat : ………………….. Alamat : …………………..
Agama : ………………….. Agama : …………………..
Status : ………………….. Status : …………………..
Penghasilan : ………………….. Penghasilan : …………………..
Gol. Darah : ………………….. Gol. Darah : …………………..
Hub. Dg klien : …………………..

II. KELUHAN UTAMA


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III. RIWAYAT PENYAKIT SEKARANG


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IV. RIWAYAT PENYAKIT DAHULU
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V. RIWAYAT PSIKOSOSIAL
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VI. RIWAYAT KESEHATAN KELUARGA (GENOGRAM)

VII. POLA FUNGSI KESEHATAN


1. Pola persepsi dan tata laksana hidup sehat
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2. Pola nutrisi dan metabolism
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3. Pola aktivitas
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4. Pola eliminasi
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5. Pola istirahat dan tidur
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6. Pola sensori dan kognitif
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7. Pola persepsi diri
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8. Pola hubungan dan peran
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9. Pola reproduksi dan seksual
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10. Pola penanggulangan stress
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11. Pola tata nilai dan kepercayaan
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VIII. PEMERIKSAAN FISIK

1. Kepala
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2. Leher
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3. Mata
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4. Telinga
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5. Hidung
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6. Dada
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7. Abdomen
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8. Genitalia
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9. Anus
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10. Punggung
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11. Musculoskeletal/Ekstremitas
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12. Integumen
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IX. PENGKAJIAN KHUSUS PRE-NATAL


1. Subyektif
 Menarche : ……………………………………………
 Lamanya : ……………………………………………
 Siklus : ……………………………………………
 Haid terakhir : ……………………………………………
 Pap smear : ……………………………………………
 Flour albus : ……………………………………………
 Dismenorhea : ……………………………………………
 Menopause : ……………………………………………
 KB : ……………………………………………
 Riwayat persalinan terdahulu
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 Riwayat kehamilan/Gravida: G …… P………………………

No Kehamilan Jenis Kehamilan Penolong Keterangan


2. Obyektif
 Vulva : ……………………………………………
 Vagina : ……………………………………………
 Uterus : ……………………………………………
 Perineum : ……………………………………………
 Cervix : ……………………………………………
3. Pemeriksaan kehamilan
 Papasi : ……………………………………………
 Auskultasi : ……………………………………………
 Perkusi : ……………………………………………
 Ukuran panggul : ……………………………………...........
4. Pemeriksaan laboratorium
 Urine : ……………………………………………
 Darah : ……………………………………………
 Feces : ……………………………………………
 Lain-lain : .............................................................
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X. TERAPI
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ANALISA DATA

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

NO DATAPENUNJANG MASALAH ETIOLOGI


DIAGNOSA KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

NO DIANGNOSA KEPERAWATAN
INTERVENSI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL TUJUAN & KH INTERVENSI RASIONAL TTD
KEP
INTERVENSI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL TUJUAN & KH INTERVENSI RASIONAL TTD
KEP
IMPLEMENTASI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL JAM IMPLEMENTASI RESPON TTD
KEP
IMPLEMENTASI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL JAM IMPLEMENTASI RESPON TTD
KEP
EVALUASI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL JAM EVALUASI TTD
KEP
EVALUASI KEPERAWATAN

Nama Klien : ......................................


Umur : ......................................
No. Register : ......................................
Ruang : ......................................

DX
NO TGL JAM EVALUASI TTD
KEP