PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA

PERIODE INTRANATAL

Nama Mahasiswa : ...................................................................................

Nomor Mahasiswa : ...................................................................................
Tanggal pengkajian : ...................................................................................
Tempat Praktek : ...................................................................................
Tanggal Praktek : ...................................................................................

DATA UMUM
Inisial Klien : ...................................................................................
Umur : ...................................................................................
Pekerjaan : ...................................................................................
Pendidikan Terakhir : ...................................................................................
Suku bangsa : ...................................................................................
Status perkawinan : ...................................................................................
Nama Suami : ...................................................................................
Alamat : ...................................................................................
Pekerjaan : ...................................................................................
Agama : ...................................................................................
Pendidikan terakhir : ...................................................................................

DATA UMUM KESEHATAN

1. Tinggi / berat
badan……………………...cm/……………………………………… kg
2. Berat badan sebelum hamil …………………………………..………...kg
3. Masalah kesehatan khusus ………………………………………………
4. Obat – obatan
………………………………………………………………………………
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5. Alergi (makanan / obat-obatan / bahan tertentu
………………………………………………………..............................
6. Diet khusus
………………………………………………………….............................
7. Menggunakan alat bantu : gigi tiruan / kaca mata / kontak lensa / alat
dengar, lain-lain, sebutkan
………………………………………………………………………………
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8. Frekuensi BAB …………………….. kali/ hari, masalah
……………………………………………………………………………..
9. Frekuensi BAK ……………………. Kali / hari, masalah
……………………………………………………………………………..
10.Kebiasaan waktu tidur
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DATA UMUM MATERNITAS
1. Kehamilan sekarang direncanakan ( ya/tidak) : ……………………………
2. Status Obstetrikus : G…P….A….. Usia kehamilan…………………………
……………………………………………………………………………….
3. HPHT ……………………………. Tafsiran partus…………………………
………………………………………………………………………………..
4. Jumlah anak dirumah
……………………………………………………………………………….

NO Jenis Cara Tempat BB Komplikasi Keadaan Umur

Kelamin lahir persalinan lahir selama saat ini
dan proses
penolong persalinan

5. Mengikuti kelas prenatal ( ya / tidak )

………………………………………………………………………………
6. Jumlah kunjungan selama kehamilan ini
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7. Masalah kehamilan yang lain
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a. Trimester I
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b. Trimester II
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c. Trimester III
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8. Masalah kehamilan sekarang
………………………………………………………………………………
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………………………………………………………………………………
9. Kontrasepsi yang pernah dipakai dan masalah yang pernah dialami selama
penggunaan alat konterasepsi ini .
………………………………………………………………………………
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Rencana KB setelah kehamilan ini
………………………………………………………………………………
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10. Makanan bayi sebelumnya ASI / PASI
………………………………………………………………………………
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11. Pendidikan kesehatan yang ingin ibu dapatkan selama perawatan (Lingkari
tanda didepan opstion)
 Relaksasi pernafasan
 Manfaat ASI dan cara menyusui yang baik
 Senam nifas
 Metode KB
 Perawatan perineum
 Perawatan payudara

Setelah bayi lahir siapa yang diharapkan membantu : suami / teman / orang tua
atau yang lain ………………………………………………………………………
Masalah persalinan yang lalu
………………………………………………………………………………………
………………………………………………………………………………………

RIWAYAT PERSALINAN SEKARANG

1. Mulai persalinan (konmtraksi / pengeluaran pervaginam ) : tgl

/jam……………………....…………………………………………………..…
………………………….....................................................................................
2. Keadaan kontraksi (frekuensi dalam 10 mnt,lamanya , kekuatan ).....................
………………………………………………………………………………......
3. Frekuensi dan kekuatan denyut jantung janin ……..x/ mnt
4. Pemeriksaan fisik :
Kenaikan BERAT BADAN selam kehamilan …………………………….kg
Tanda vital : TD = ……… mmHg ; Nadi = …..x /mnt ; suhu = ………C; P=
……x/mnt
 Kepala / leher
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  Dada (jantung, paru-paru)
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 Payudara
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 Abdomen (secara umum dan pemeriksaan)
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 Kontraksi
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 DJJ
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 Ekstrimitas (edema / tidak)
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 Refleks
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5. Pemeriksaan dalam
Jam pemeriksaan Oleh Hasil
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6. Ketuban (utuh / pecah ) jika sudah pecah tgl /jam …………..Warna

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7. Laboratorium
Tanggal dan jenis Hasil pemeriksaan Interpretasi
pemeriksaan normal
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Terapi yang diberikan

Tanggal Jenis terapi Rute Dosis Indikasi terapi

terapi
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DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : Rp
………………………………………………………………………………………
………………………………………………………………………………………
Bagaimana perasaan anda terhadap kehamilan sekarang
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Bagaimana perasaan pasangan anda terhadap kehamilan sekarang
…………………........................................................................................................
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Jelaskan respon sibling terhadap kehamilan sekarang
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LAPORAN PERSALINAN

Kala I
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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 IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu
Dx Tindakan
Tgl/jam
Kep
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Waktu Catatan Perkembangan
TT TT
Tgl/jam (SOAP)
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Kala 2
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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Keadaan Umum bayi baru lahir
Berat badan :
Panjang badan :
Lingkar kepala :
Lingkar dada :
Lingkar perut :
Lingkar lengan atas :
APGAR SKOR
No Tgl/Jam Karakteristik 1 5 10
yang dinilai

Denyut jantung

Pernafasan

Refleks

Tonus otot

Warna kulit

Total Menit 1 :
Menit 5 :
Menit 10 :
Kesimpulan :
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3. Kala III
Tanggal Jam Hasil observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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Kala IV
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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ASUHAN KEPERAWATAN

Tanggal Jam Diagnosa Tujuan Intervensi Implementasi Evaluasi

keperawatan