Format Mater
Format Mater
A. IDENTITAS
Nama Pasien :…………… Nama Suami :………………
Umur :…………… Umur :……… …......
Suku Bangsa :………....... Suku Bangsa :………….......
Agama :…………..... Agama :………….......
Pendidikan :……… ….. Pendidikan :………… …
Pekerjaan :…………… Pekerjaan :………… …..
Alamat Rumah :…………… Alamat Rumah :………………
Status Perkawinan :……………… Status Perkawinan :………………
B. RIWAYAT KEPERAWATAN
1. Riwayat Obstetri
a. Riwayat Menstruasi
Menarche umur :…………… ………. Siklus :…………………… ………
Banyaknya :…………………… … Lamanya :……………………….........
HPHT :………………………. Keluhan :………………………........
c. Kehamilan Sekarang
Diagnosa Kehamilan :..............................................................................
Usia Kehamilan :..............................................................................
Imunisasi :...............................................................................
ANC :................................................................................
Keluhan selama hamil dan keluhan saat ini :................................
Pengobatan selama hamil :...........................................................
Pergerakkan janin ...........................................................................
Rencana perawatan bayi ( ) sendiri ( ) orang tua ( ) lain lain
Keterangan.......................................................................................
Kesanggupan dan pengetahuan dalam merawat bayi :........
Breast care :..................................................
Perineal care :.............................................................
Nutrisi :............................................................
Senam nifas : .....................................................................
KB :........................................................................
Menyusui : ....................................................................
d. Riwayat Keluarga Berencana
Melaksanakan KB : (…. ) Ya (……)Tidak
Bila ya jenis kontrasepsi apa yang digunakan……..........…
Sejak kapan menggunakan kontrasepsi………………….…
Masalah yang terjadi…………………
e. Riwayat Kesehatan
a. Penyakit yang pernah dialami Ibu……………………...……..
b. Pengobatan yang didapat……………
1. Riwayat penyakit keluarga………………………..
2. Keterangan : ……………………..…………..
c. Riwayat Lingkungan
1. Kebersihan……………………………………………………
2. Bahaya…………………………………………………..
3. Lainnya. Sebutkan…………………………………………………
f. Aspek Psikososial
1. Apakah kehamilan ini direncanakan oleh ibu dan pasangan ??.........
2. Harapan yang ibu inginkan selama kehamilan.............................................
3. Bagaiman dukungan pasangan terhadap kehamilan ini......................
4. Bagaimana sikap anggota keluarga lainnya terhadap kehamilan ini............
5. Lainnya. Sebutkan.....................................................................
g. Kebutuhan Dasar Khusus
Pola Nutrisi
Frekuensi makan............................................................................
Nafsu makan Jenis makanan rumah.......................................................
Makanan yang tidak disukai/ alergi pantangan.........................................
Pola eliminasi
BAK
Frekuensi ..................................................................................
Warna.........................................................................................
Keluhan saat BAK............................................................................
BAB
Frekuensi .......................................................................................
Warna...............................................................................................
Bau...............................................................................................
Konsistensi..........................................................................................
Keluhan................................................................................................
Pola personal hygiene
Mandi..................................................................................................
Oral Hygiene...................................................................................
Cuci Rambut.............
Lainnya.........................................................................................
Pola istirahat dan tidur
Lama tidur.....................................................................
Kebiasaan sebelum tidur...............................................
Keluhan.........................................................................
Pola aktifitas dan latihan............................................................
Kegiatan dalam pekerjaan........................................................................
Waktu bekerja......................................................................................
Olah raga...........................................................................................
Frekuensi.................................................................................................
Kegiatan waktu luang........................................................................
Keluhan dalam aktivitas..................................................
Kebiasaan yang mempengaruhi kesehatan....................
Merokok...................................................................
Minuman keras........................................................................................
Ketergantungan obat.........................................................
C. PEMERIKSAAN FISIK
Keadaan umum :……………… Kesadaran………
Mata
Kelopak mata..................................................................
Gerakkan mata.......................................................................
Konjungtiva..............................................................................
Sklera.................................................................................................
Pupil.................................................................................................
Akomodasi...............................................................................................
Lainnya. Sebutkan....................................................................................
Hidung
Reaksi allergi
Sinus..........................................................................................................
Lainnya.......................................................................................................
Mulut dan Tenggorokkan
Gigi geligi..............................................................
Kesulitan menelan Lainnya..............................................................................................
Dada & Aksila
Mammae : ..............................................................................
Aerolla mammae.................................................................................
Papila mammae
Colostrum...............................................................................................
Pernapasan
Jalan napas...............................................................................................
Suara napas................................................................................
Penggunaan otot bantu pernapasan........................................................
Sirkulasi Jantung
Frekuensi nadi..........................................................................................
Irama................................................................
Kelainan bunyi jantung..................................................................
Keterangan :..........................................................................................
Abdomen
Membesar…………………………………………………………….
Linea…………………………………………………
Striae…………………………………………………………………….
Leopold 1……………………………………………………………..
Leopold II…………………………………………………….
Leopold III……………………………………………………
Leopold IV………………………………
DJJ……………………………………………………………………………………….
Genital
Keputihan………………………………………………………………..
Pap Smear……………………………………………………………….
Lainnya…………………………………………………………………………………….
Ekstrimitas
Turgor kulit………………………………………………...
Warna kulit………………………………………………
Kesulitan dalam pergerakkan…………………
Lainnya……………………………………………………………………………..
D. DATA PENUNJANG
Laboratorium…………………………………………………………………………...........
…………………………………………………………………………………………………...…
….…………………………………………………………………………………….............
USG…………………………………………………………………………………………
………………………………………………………………………………………………….......
.......……………………………………………………………………………………………
Terapi yang didapat…………………………………………..........................................
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
E. DATA TAMBAHAN
……………………………………………………………………………………………………………
………………………………………………….......................................................................................
Surabaya,……………………..
Pemeriksa
(………………………………)
SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
FORMAT PENGKAJIAN GANGGUAN SISTEM REPRODUKSI
KEPERAWATAN MATERNITAS
A. IDENTITAS
Nama Pasien :……………… Nama Suami :………………..
Umur :................... Umur :.....................
Suku Bangsa :............................ Suku Bangsa :.............................
Agama :.............................. Agama :……….
Pendidikan :…………… Pendidikan :…………
Pekerjaan :…………… Pekerjaan :…………
Alamat Rumah :……… …. Alamat Rumah :…………
Status Perkawinan : Status Perkawinan :…………..
B. STATUS KESEHATAN SAAT INI
Alasan kunjungan ke rumah sakit......................................................
Keluhan utama saat ini.............................................................
Timbulnya keluhan ..................................................................
Faktor yang memperberat........................................................
Upaya yang dilakukan untuk mengatasi.............................
Diagnosa Medik............................................................................
C. RIWAYAT KEPERAWATAN
a. Riwayat Obstetri
i. Riwayat Menstruasi
Menarche umur ………………. Siklus ………………….
Mata
Kelopak mata
Gerakkan mata..................................
Konjungtiva...................................................................................
Sklera........................................................................................
Pupil.........................................................................................................
Akomodasi......................................................................................
Lainnya. Sebutkan.................................................
Hidung
Reaksi allergi..............................................................................
Sinus...................................................................................
Lainnya.....................................................................................
Mulut dan Tenggorokkan
Gigi geligi......................................
Kesulitan menelan....................................
Lainnya..............................................................................
Dada & Aksial
Mammae : ..................................................................................
Aerolla mammae............................................................
Papila mammae..................................................................
Colostrum......................................................
Pernapasan
Jalan napas...................................................................................
Suara napas.........................................
Penggunaan otot bantu pernapasan.................................................
Sirkulasi Jantung
Frekuensi nadi....................................................................
Irama.................................................................................................
Kelainan bunyi jantung.......................................................
Keterangan :..............................................................................
Abdomen
Perineum/ vulva………………………………………
Vesika Urinaria……………………………………
Striae……………………………………………………………
Lainnya…………………………………………………………
Genital
Keputihan……………………………………………………………
Pap Smear……………………………………………
Lainnya………………………….………………………………
Ekstrimitas
a. Turgor kulit
b. Warna kulit
c. Kesulitan dalam pergerakkan
d. Lainnya……………………………………………………………..
C. DATA PENUNJANG
Laboratorium…………………………………………………………….
USG……………………………………………………………...
E. DATA TAMBAHAN
………………………………………………………………………………………………................
.....................................................................................................................................................
Surabaya,…… …………….
Pemeriksa
(…………………….)
ASUHAN KEPERAWATAN MATERNITAS
FORMAT PENGKAJIAN PADA POST PARTUM
I. IDENTITAS
Nama pasien : .................................. Nama suami : ..................................
Umur : .................................. Umur : ..................................
Suku/bangsa : .................................. Suku/bangsa : ..................................
Agama : .................................. Agama : ..................................
Pendidikan : .................................. Pendidikan : ..................................
Pekerjaan : .................................. Pekerjaan : ..................................
Alamat : .................................. Alamat : ..................................
Status perkawinan : ..................................
C. Genogram
D. Post Partum Sekarang
Riwayat persalinan sekarang : ................................................................................................
Tipe persalinan : Spontan/bantuan ..............................
Lama persalinan :
Kala I : ..................... jam Kala III : ..................... jam
Kala II : ..................... jam Kala IV : ..................... jam
E. Rencana Perawatan Bayi : ( ) sendiri ( ) orang tua ( ) lain-lain
Kesanggupan dan pengetahuan dalam merawat bayi :
Breast care : .........................................
Perineal care : .........................................
Nutrisi : .........................................
Senam nifas : .........................................
KB : .........................................
Menyusui : .........................................
3. Riwayat Kesehatan
Pengobatan yang pernah dialami ibu : ....................................................................................
Pengobatan yang didapat : ....................................................................................
Riwayat penyakit keluarga
( ) Diabetes mellitus
( ) Penyakit jantung
( ) Hipertensi
( ) Penyakit lainnya : sebutkan .........................................
4. Riwayat Lingkungan
Kebersihan : ..................................................................................................................
Bahaya : ..................................................................................................................
Lainnya, sebutkan : ..................................................................................................................
5. Aspek Psikososial
a. Persepsi ibu setelah bersalin : ...............................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari? .....................
Bila ya bagaimana ....................................................................................................................
c. Harapan yang ibu inginkan setelah bersalin : ...............................................................
d. Ibu tinggal dengan siapa : ...............................................................
e. Siapa orang yang terpenting bagi ibu : ...............................................................
f. Sikap anggota keluarga terhadap keadaan saat ini : ...............................................................
g. Kesiapan mental untuk menjadi seorang ibu : ( ) ya ( ) tidak
7. Pemeriksaan Fisik
Keadaan umum : ..................................
Tekanan darah : ..................................
Respirasi : ..................................
Berat badan : ............................. kg
Kesadaran : ..................................
Nadi : .................... /menit
Suhu : ............................. °C
Tinggi badan : .................................
Kepala, mata, kuping, hidung dan tenggorokan :
Bentuk kepala........................................................................................................................
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 :..................................................................................................................
Areolla mammae :..................................................................................................................
Papilla mammae : ..................................................................................................................
Colostrum :..................................................................................................................
Pernafasan :
Jalan nafas : ...............................................................................................................
Suara nafas : ...............................................................................................................
Menggunakan otot-otot bantu pernafasan : ..............................................................................
Lainnya, sebutkan :...............................................................................................................
Sirkulasi jantung :
Kecepatan denyut apical :......................................................................... /menit
Irama : ......................................................................................................
Kelainan bunyi jantung :......................................................................................................
Sakit dada : ......................................................................................................
Timbul :......................................................................................................
Lainnya, sebutkan :......................................................................................................
Abdomen :
Mengecil : ...............................................................................................................
Linea & striae : ...............................................................................................................
Luka bekas operasi :...............................................................................................................
TFU : ...............................................................................................................
Kontraksi : ...............................................................................................................
Lainnya, sebutkan :...............................................................................................................
Genitourinary :
Perineum : ...............................................................................................................
Lokhea: ...............................................................................................................
Vesika urinaria :
...............................................................................................................
Lainnya, sebutkan :
...............................................................................................................
Ekstremitas (integumen/muskuloskeletal)
Turgor kulit : ...............................................................................................................
Warna kulit : ...............................................................................................................
Kontraktur pada persendian ekstremitas : ................................................................................
Kesulitan dalam pergerakan : ...................................................................................................
Lainnya, sebutkan :
...............................................................................................................
Surabaya, .....................
Pemeriksa
(...............................)
ASUHAN KEPERAWATAN MATERNITAS
FORMAT PENGKAJIAN PADA GANGGUAN REPRODUKSI
I. Identitas klien
Nama : ………………………………………………………………….
Tempat/tgl lahir : ………………………………………………………………….
Umur : ………………………………………………………………….
Jenis kelamin : ………………………………………………………………….
Alamat : ………………………………………………………………….
Status perkawinan : ………………………………………………………………….
Agama : ………………………………………………………………….
Suku : ………………………………………………………………….
Pendidikan : ...………………………………………………………………..
Pekerjaan : ………………………………………………………………….
Lama bekerja : ………………………………………………………………….
Tanggal masuk RS : ………………………………………………………………….
Sumber informasi : ………………………………………………………………….
Keluarga terdekat yang dapat segera dihubungi : ………………………………….
Pendidikan : ………………………………………………………………….
Pekerjaan : ………………………………………………………………….
Alamat : ………………………………………………………………….
I. Biodata
A. Identitas Ibu
Nama :
Umur :
Agama :
Kebangsaan :
Status Perkawinan :
Pendidikan :
Pekerjaan :
Alamat :
No. CN :
DX :
Tanggal masuk :
Tanggal pengkajian :
B. Identitas Suami
Nama :
Umur :
Agama :
Kebangsaan :
Pendidikan :
Pekerjaan :
Alamat :
E. Riwayat Perkawinan
F. Riwayat Menstruasi
H. Riwayat Ginekologi
I. Pola Kebiasaan
J. Pola nutrisi
K. Pola Euminasi
N. Pola Aktivitas
O. Riwayat Psikologis
P. Riwayat Sosial
Q. Riwayat Spiritual
III. Pemerikasan Umum
a. K/U :
b. Kesadaran :
Td :
RR :
c. BB :
d. TTP :
e. C3P1A1 :
f. Gerakan janin (+) :