FORMAT PENGKAJIAN ANTENATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
..............................................................................................................................................…………………………………………………………………

……………………..…

2. Keluhan utama saat ini : ..................................................................……..................

..............................................................................................................................................…………………………………………………………………
………………….……
3. Riwayat Kehamilan saat ini

4. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :
b. Riwayat kehamilan, persalinan, nifas :

Anak
Kehamilan Persalinan Komplikasi nifas Anak
ke
U
mu
Ta r
N Peny Penolo Peny Lase
hu ke Jenis Infeksi Perdarahan Jenis BB pj
o ulit ng ulit rasi
n ha
mil
an

Genogram

2. RIWAYAT KELUARGA BERENCANA :

 Melaksanakan KB : ( ) ya ( ) tidak
 Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
 Sejak kapan menggunakan kontrasepsi : ................................................................
 Masalah yang terjadi : ............................................................................................

3. RIWAYAT KESEHATAN :
 Penyakit yang pernah dialami ibu : ........................................................................
 Pengobatan yang didapat : ......................................................................................
 Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

4. RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................…………….......
- Bahaya : …………......................................................................................................................
- Lainnya sebutkan : .................................................................................…………………….....................

5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

6. KEBUTUHAN DASAR KHUSUS :

a. Pola Nutrisi
 Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
 Jenis makanan rumah : ................................................................................….
 Makanan yang tidak disukai/ alergi/ pantangan : .............................................
 b. Pola eliminasi :
 BAK
- Frekwensi : ....................kali
- Warna : .......................……………………………………………….
- Keluhan saat BAK : .................................................………......................

 BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : .............……………………………………………….........
- Keluhan : ..............................................................................………....
c. Pola personal hygiene
 Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
 Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
 Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
 Lama tidur : ............................jam/hari
 Kebiasaan sebelum tidur : ................................................................................
 Keluhan : ..........................................................................................................

e. Pola aktifitas dan latihan

 Kegiatan dalam pekerjaan : ..............................................................................
 Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
 Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
 Kegiatan waktu luang : .....................................................................................
 Keluhan dalam beraktifitas : ............................................................................

f. Pola kebiasaan yang mempengaruhi kesehatan

 Merokok : ..............................................................................................
 Minuman keras : ..............................................................................................
 Ketergantungan obat : ..............................................................................................

7. PEMERIKSAAN FISIK
 Keadaan umum : ......................................Kesadaran : .........................
 Tekanan darah : ......................................Nadi : .............x/menit
 Respirasi : ......................................Suhu : .......…........C
 Berat badan : ......................kg Tinggi badan : ................cm

Kepala, mata kuping, hidung dan tenggorokan :

Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
 Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................

Dada dan Axilla

  Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
 Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

Pernafasan
 Jalan nafas : .....................................................................................................
 Suara nafas . : ....................................................................................................
 Menggunakan otot-otot bantu pernafasan : ............................................................
 Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ...............................................................................................
 Kelainan bunyi jantung : ........................................................................................
 Sakit dada : ...............................................................................................
 Timbul .: ...............................................................................................
 Lainnya sebutkan : ..............................................................................................

Abdomen
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak
 Leopold I :
 Leopold II :
 Leopold III:
 Leopold IV:
 Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :

Genitourinary
 Perineum : ...............................................................................................
 Vesika Urinasria : ...............................................................................................
 Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
 Vagina : varises: ya/ tidak
 Kebersihan :
 Keputihan :
 Jenis/warna :

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

8. Kesiapan dalam kehamilan dan persalinan:

a. Senam hamil
b. Rencana tempat melahirkan
c. Perlengkapan kebutuhan bayi dan ibu
d. Kesiapan mental ibu dan keluarga
e. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses persalinan

9. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
...............................................................................................................................................................................................................................
..............................................................................................................................................

10. Data Tambahan

............................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................
....................................................
 Surabaya, ........................................
Pemeriksa

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

FORMAT PENGKAJIAN INTRANATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
..............................................................................................................................................…………………………

2. Keluhan utama saat ini :

..................................................................……...............................................................................................................................................................

.…………………………………………………………………………………….……

3. Riwayat Persalinan saat ini

4. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN
11. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :
b. Riwayat kehamilan, persalinan, nifas :

Anak
Kehamilan Persalinan Komplikasi nifas Anak
ke
U
mu
Ta r
N Peny Penolo Peny Lase
hu ke Jenis Infeksi Perdarahan Jenis BB pj
o ulit ng ulit rasi
n ha
mil
an

Genogram

Riwayat keluarga berencana :

Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................

Riwayat kesehatan :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

Riwayat lingkungan :
- Kebersihan : ...........................................................................................................…………….......
- Bahaya : …………......................................................................................................................
- Lainnya sebutkan : .................................................................................…………………….....................

Aspek psikososial :
Persepsi ibu tentang keluhan/ penyakit : ................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ? ............
Bila ya bagaimana ..................................................................................................
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

Kebutuhan dasar khusus (Di rumah dan di rs) :

Pola Nutrisi
Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : ................................................................................….
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : .......................……………………………………………….
Keluhan saat BAK : .................................................………......................

BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : .............……………………………………………….........
Keluhan ....................................................................………....
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
Ketergantungan obat : ..............................................................................................
Pemeriksaan fisik
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : .....................................Suhu : .......…........C
Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :
Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
 Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................
Dada dan Axilla
 Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
  Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

Pernafasan
 Jalan nafas : .....................................................................................................
 Suara nafas . : ....................................................................................................
 Menggunakan otot-otot bantu pernafasan : ............................................................
 Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ...............................................................................................
 Kelainan bunyi jantung : ........................................................................................
 Sakit dada : ...............................................................................................
 Timbul .: ...............................................................................................
 Lainnya sebutkan : ..............................................................................................

Abdomen
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak
 Leopold I :
 Leopold II :
 Leopold III:
 Leopold IV:
 Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :

Genitourinary
 Perineum : ...............................................................................................
 Vesika Urinasria : ...............................................................................................
 Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
 Vagina : varises: ya/ tidak
 Kebersihan :
 Keputihan :
 Jenis/warna :

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

Kesiapan dalam kehamilan dan persalinan:

Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses persalinan

Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat: ....................................................................................................................................................................................

Data Tambahan
..........................................................................................................................................................................................
Surabaya, ........................................
Pemeriksa

(..................................................)
 FORMAT PENGKAJIAN POST PARTUM

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
Nama pasien : ................................. Nama Suami : …….....................
Umur : ....................... th Umur : ....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ……...................
Agama : ................................. Agama : ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

1. Keluhan utama saat ini : ..................................................................……..................
..............................................................................................................................................…………………………………………………………………
………………….……
2. Riwayat Kondisi saat ini

3. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :
b. Riwayat kehamilan, persalinan, nifas :

Anak
Kehamilan Persalinan Komplikasi nifas Anak
ke
U
mu
Ta r
N Peny Penolo Peny Lase
hu ke Jenis Infeksi Perdarahan Jenis BB pj
o ulit ng ulit rasi
n ha
mil
an

Genogram

Riwayat Persalinan Dan Post Partum Sekarang

Keluhan his
Pengeluaran pervaginan
Kala persalinan
Kala 1
Kala 2
Kala 3
Kala 4

DATA BAYI
Bayi lahir tanggal/ jam..................................
Jenis kelamin................................................
Nilai APGAR..................................................
BB/PB/Lingkar kepala bayi.................gram..................cm................cm
Kelainan Kepala
Suhu...........................c
Anus: berlubang/ tertutup
Perawatan tali pusat.................................
Perawatan mat

RIWAYAT KELUARGA BERENCANA :

Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................

RIWAYAT KESEHATAN :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
 ( ) Penyakit lainnya : sebutkan ......................................................................

RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................…………….......
- Bahaya : …………......................................................................................................................
- Lainnya sebutkan : .................................................................................…………………….....................

ASPEK PSIKOSOSIAL :
Persepsi ibu tentang persalinan saat ini: ................................................................
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

KEBUTUHAN DASAR KHUSUS (Di rumah dan di rs) :

Pola Nutrisi
Frekwensi makan : .............................. x sehari
Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : ................................................................................….
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : .......................……………………………………………….
Keluhan saat BAK : .................................................………......................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : .............……………………………………………….........
Keluhan ....................................................................………....
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
Ketergantungan obat : ..............................................................................................

PEMERIKSAAN FISIK
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : .....................................Suhu : .......…........C
Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :
Kepala : Bentuk ..........................................................
 Keluhan :........................................................
Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
 Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................
Dada dan Axilla
 Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
 Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

Pernafasan
 Jalan nafas : .....................................................................................................
 Suara nafas . : ....................................................................................................
 Menggunakan otot-otot bantu pernafasan : ............................................................
 Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ...............................................................................................
 Kelainan bunyi jantung : ........................................................................................
 Sakit dada : ...............................................................................................
 Timbul .: ...............................................................................................
 Lainnya sebutkan : ..............................................................................................
Abdomen
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak
 Bising usus

Perineum dan Genital

 Integritas Vagina :
 Perineum : ...............................................................................................
 Tanda REEDA
R:Rednes : ya/tidak
E:Edema : ya/tidak
E: Echimosis : ya/tidak
D: Discharge : ya/tidak
A: Approximate : baik/tidak
 Lokia : jumlah warna/jenis bau
 Hemorrhoid : derajat lokasi nyeri

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit :
 Warna kulit :
 Edema :
 Kontraktur pada persendian ekstrimitas :
 Tanda Homan : +/-
 Kesulitan dalam pergerakan :
 Lainnya sebutkan :

Kesiapan dalam perawatan bayi:

Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses persalinan
Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
.......................................................................................................................................................................................................................................
......................................................................................................................................

Data Tambahan
............................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................
....................................................
Surabaya, ........................................
Pemeriksa

FORMAT PENGKAJIAN
GANGGUAN SISTEM REPRODUKSI
UNIT KEPERAWATAN MATERNITAS
Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
Nama pasien : ................................. Nama Suami : …….....................
Umur : ....................... th Umur : ....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ……...................
Agama : ................................. Agama : ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

A. Alasan kunjungan ke rumah sakit : ....................................................……................
..............................................................................................................................................…………………………………………………………………

……………………..…

B. Keluhan utama saat ini : ..................................................................……..................

..............................................................................................................................................…………………………………………………………………
………………….……
C. Riwayat penyakit sekarang ;
............................................................................................................................................................................................................................................
...........................
D. Riwayat penyakit dahulu :
........................................................................................................................................................................................................................................
..............................
E. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN
12. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
 HPHT : ............................ Keluhan : ...........................
(..................................................)
b. Riwayat kehamilan, persalinan, nifas :

Anak
Kehamilan Persalinan Komplikasi nifas Anak
ke
U
mu
Ta r
N Peny Penolo Peny Lase
hu ke Jenis Infeksi Perdarahan Jenis BB Pj
o ulit ng ulit rasi
n ha
mil
an

Genogram

13. RIWAYAT KELUARGA BERENCANA :

 Melaksanakan KB : ( ) ya ( ) tidak
 Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
 Sejak kapan menggunakan kontrasepsi : ................................................................
 Masalah yang terjadi : ............................................................................................

14. RIWAYAT KESEHATAN :

 Penyakit yang pernah dialami ibu : ........................................................................
 Pengobatan yang didapat : ......................................................................................
 Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

15. RIWAYAT LINGKUNGAN :

- Kebersihan : ...........................................................................................................…………….......
- Bahaya : …………......................................................................................................................
- Lainnya sebutkan : .................................................................................…………………….....................

16. ASPEK PSIKOSOSIAL :

a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
17. KEBUTUHAN DASAR KHUSUS :
a. Pola Nutrisi
 Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
 Jenis makanan rumah : ................................................................................….
 Makanan yang tidak disukai/ alergi/ pantangan : .............................................

b. Pola eliminasi :
 BAK
- Frekwensi : ....................kali
- Warna : .......................……………………………………………….
- Keluhan saat BAK : .................................................………......................

 BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : .............……………………………………………….........
- Keluhan : ..............................................................................………....
c. Pola personal hygiene
 Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
 Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
 Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
 Lama tidur : ............................jam/hari
 Kebiasaan sebelum tidur : ................................................................................
 Keluhan : ..........................................................................................................

e. Pola aktifitas dan latihan

 Kegiatan dalam pekerjaan : ..............................................................................
 Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
 Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
 Kegiatan waktu luang : .....................................................................................
 Keluhan dalam beraktifitas : ............................................................................

f. Pola kebiasaan yang mempengaruhi kesehatan

 Merokok : ..............................................................................................
 Minuman keras : ..............................................................................................
 Ketergantungan obat : ..............................................................................................

18. PEMERIKSAAN FISIK

 Keadaan umum : ......................................Kesadaran : .........................
 Tekanan darah : ......................................Nadi : .............x/menit
 Respirasi : ......................................Suhu : .......…........C
 Berat badan : ......................kg Tinggi badan : ................cm

Kepala, mata kuping, hidung dan tenggorokan :

Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
  Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................

Dada dan Axilla

 Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
 Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

Pernafasan
 Jalan nafas : .....................................................................................................
 Suara nafas . : ....................................................................................................
 Menggunakan otot-otot bantu pernafasan : ............................................................
 Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ...............................................................................................
 Kelainan bunyi jantung : ........................................................................................
 Sakit dada : ...............................................................................................
 Timbul .: ...............................................................................................
 Lainnya sebutkan : ..............................................................................................

Abdomen
 Mengecil : ................................................................................................
 Linea dan striae : ...............................................................................................
 Luka bekas operasi : ...............................................................................................
 Kontraksi : ................................................................................................
 Lainnya sebutkan : ................................................................................................

Genitourinary
 Perineum : ...............................................................................................
 Vesika Urinasria : ...............................................................................................
 Lainnyasebutkan : ...............................................................................................

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

d. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
.........................................................................................................................................................................................................................
....................................................................................................................................................

e. Data Tambahan
......................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................
................................
Surabaya, ........................................
Pemeriksa

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