LAPORAN KASUS

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Oleh :
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NIM ...............................

PROGRAM STUDI NERS

STIKES WIDYAGAMA HUSADA
2018
 LEMBAR PENGESAHAN

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Oleh :
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NIM ...............................

Mengetahui, Malang, ................ 20.....

Penguji Pendidikan Penguji Lahan

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 FORMAT PENGKAJIAN
UNIT KEPERAWATAN MATERNITAS
Tanggal masuk : ........................................ Jam masuk : ........................................
Ruang/kelas : ........................................ Kamar no. : ........................................
Pengkajian tanggal : ........................................ Jam pengkajian : ........................................

I. IDENTITAS
Nama klien : .................................. Nama suami : ..................................
Umur : .................................. Umur : ..................................
Suku/bangsa : .................................. Suku/bangsa : ..................................
Agama : .................................. Agama : ..................................
Pendidikan : .................................. Pendidikan : ..................................
Pekerjaan : .................................. Pekerjaan : ..................................
Alamat : .................................. Alamat : ..................................
Status perkawinan : ..................................

II. KELUHAN UTAMA / ALASAN KUNJUNGAN

Saat MRS :
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Saat Pengkajian :
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III. RIWAYAT PENYAKIT SEKARANG

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IV. RIWAYAT PERNIKAHAN

Status pernikahan : .....................................................
Jika menikah : berapa kali .............................. lamanya ................... usia .......................

V. RIWAYAT OBSTETRI
1. Riwayat Menstruasi
Menarche : umur ......................th HPHT : ..................................
Banyaknya : .................................. Siklus : teratur ( ) tidak ( )
Warna : .................................. Lamanya : ..................................
Bentuk haid : encer/bergumpal/flek/lainnya .........................
Bau haid : anyir/busuk/lainnya ........................................
Keluhan : Fluor albus/Dismenorhoe/Spoting/Menorraghia/Metrorhagia/PMS
Lainnya.......................

2. Riwayat Kehamilan, Persalinan, Nifas Yang Lalu

Anak ke Kehamilan Persalinan Komplikasi nifas Anak Keadaan anak
No Th UK Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan JK BB PJ sekarang
.
3. Riwayat Hamil Ini
Taksiran Persalinan (TP) : ............................................
Keluhan :
a. Trimester I : .................................................................................................................
b. Trimester II : .................................................................................................................
c. Trimester III : .................................................................................................................
Perawatan antenatal : di .............................................. berapa kali .....................................
Gerakan janin : .................................................................................................................
Tanda bahaya dan penyulit kehamilan : .......................................................................................
Obat/jamu yang pernah dan sedang dikonsumsi : ........................................................................

4. Riwayat Persalinan Sekarang

Tipe Persalinan : Spontan / Bantuan ..................................................................................
Tgl & Jam Persalinan : .................................................................................................................
Lama Persalinan : Kala I ........................... jam Kala III .............................. jam
Kala II ......................... jam Kala IV .............................. jam
BB Lahir Anak : ............................................
Jenis Kelamin Anak : ............................................
Apgar Score : ............................................
Jumlah Perdarahan : ............................................
Data Lain-lain
: .......................................................................................................................................................
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..

5. Riwayat Nifas
Tanggal ............................................ Jam ....................................
Involutio :
- TFU : .............................................................................
- Kontraksi : .............................................................................
Lochea :
- Warna : .............................................................................
- Jumlah : .............................................................................
- Jenis : .............................................................................
Laktasi :
- Kolostrum : .............................................................................
- ASI : .............................................................................
Keluhan Lain :
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6. Rencana Perawatan Bayi

a. Sendiri/orang tua/lain-lain .......................................................................................................
b. Kesanggupan dan pengetahuan dalam merawat bayi :
- Breast Care : .....................................................
- Perineal Care : .....................................................
- Nutrisi : .....................................................
- Senam nifas : .....................................................
- KB : .....................................................
- Menyusui : .....................................................

7. Riwayat KB
Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : .............................................................
Sejak kapan menggunakan kontrasepsi : .............................................................
Masalah yang terjadi : ....................................................................................................
VI. RIWAYAT KESEHATAN KELUARGA
1. Keturunan kembar : ya / tidak
2. Penyakit menular / keturunan : .........................................................................................
3. Genogram :

VII. RIWAYAT KESEHATAN YANG LALU

Penyakit yang pernah dialami: ......................................................... th ............................
Pengobatan yang pernah didapat : ....................................................................................
Riwayat operasi yang pernah dialami (jenis, tempat dan waktu) :
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VIII. RIWAYAT PSIKOSOSIAL SPIRITUAL

1. Komunikasi : ...............................................................................................................
2. Keadaan emosional :
( ) kooperatif ( ) depresi ( ) agresif ( ) hipoaktif
( ) bingung ( ) menarik diri ( ) cemas ( ) marah
( ) hiperaktif ( ) gelisah
3. Hubungan dengan keluarga :
( ) akrab ( ) terganggu ( ) lainnya ......................................
4. Hubungan dengan orang lain :
( ) akrab ( ) terganggu ( ) lainnya .......................................
5. Proses berfikir :
( ) terarah ( ) bingung ( ) ilusi ( ) halusinasi
6. Ibadah / spriritual :
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7. Respon ibu terhadap kondisi saat ini : ........................................................................
8. Dukungan keluarga : ...................................................................................................
9. Pengambilan keputusan dalam keluarga : ...................................................................
10. Beban kerja dan kegiatan sehari-hari : ........................................................................
11. Tempat dan petugas yang diinginkan untuk bersalin : ................................................
12. Riwayat Psikososial Post Partum :
- Taking in : 1-2 hari post partum, ibu cenderung pasif, kelelahan
- Taking Hold : 3-10 hari post partum, ibu memerlukan dukungan dlm pemberian ASI
- Letting Go : 10 hari psot patrum,

IX. POLA DASAR KHUSUS

a. Pola Nutrisi
1) Frekuensi makan : ......................................................................................................
2) Nafsu makan : ......................................................................................................
3) Jenis makanan : ......................................................................................................
4) Makanan yang tidak disukai/alergi/pantangan : ............................................................
b. Pola Eliminasi
BAK
 1) Frekwensi : ........................... kali
2) Warna : .................................
3) Keluhan : .................................
BAB
1) Frekwensi : ...........................  /hari
2) Warna : .....................................
3) Bau : .....................................
4) Konsistensi :.....................................
5) Keluhan : .....................................
c. Pola Personal Hygiene
1) Mandi
 Frekuensi : .....................................  /hari
 Sabun : ( ) ya ( ) tidak
2) Oral hygiene
 Frekuensi : .....................................  /hari
 Waktu : ( ) pagi ( ) sore ( ) setelah makan
3) Cuci rambut
 Frekuensi : .....................................  /hari
 Shampoo : ( ) ya ( ) tidak
4) Keluhan : ..............................................................
d. Pola Istirahat Tidur
1. Lama tidur : ................................................................................................
2. Kebiasaan sebelum tidur : ........................................................................
3. Keluhan : ................................................................................................
e. Pola Aktivitas dan Latihan
1. Kegiatan dalam pekerjaan :
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2. Waktu bekerja : ( ) pagi ( ) sore ( ) malam
3. Olahraga : ( ) ya ( ) tidak
Jenisnya : ................................................................
Frekwensi : ................................................................
4. Kegiatan waktu luang : ................................................................................................
5. Keluhan dalam aktifitas : ................................................................................................
f. Pola Kebiasaan yang Mempengaruhi Kesehatan
1. Merokok : ......................................................................................................
2. Minuman keras : ......................................................................................................
3. Ketergantungan obat : ......................................................................................................

X. PEMERIKSAAN FISIK
Keadaan umum : .................................. Kesadaran : ..................................
Berat badan : ............................. kg Tinggi badan : ..................................
a. Tanda-tanda Vital :
- Suhu : .....................................
- TD : .....................................
- RR : .....................................
- N : .....................................
b. Pemeriksaan Kepala dan Leher :
- Kepala-rambut: ...................................................................................................................
- Wajah : ...................................................................................................................
- Mata : ...................................................................................................................
- Telinga: ...................................................................................................................
- Mulut/faring : ...................................................................................................................
- Leher : ...................................................................................................................
c. Pemeriksaan Integumen :
- Warna : ...................................................................................................................
- Turgor : ...................................................................................................................
- Tekstur/kekenyalan : ..........................................................................................................
 - Kelembaban : ...................................................................................................................
- Kelainan pada kulit : .......................................................................................................
d. Dada/thorax :
- Paru : ..................................................................................................................................
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- Jantung : .............................................................................................................................
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e. Payudara :
- Inspeksi : ............................................................................................................................
- Palpasi : ............................................................................................................................
- Produksi ASI (kolostrum) : ................................................................................................
- Keluhan : ............................................................................................................................
f. Pemeriksaan abdomen :
- Inspeksi : ............................................................................................................................
- Palpasi : ............................................................................................................................
- Auskultasi : ........................................................................................................................
- Keluhan : ............................................................................................................................
g. Pemeriksaan genetalia :
- Inspeksi : ............................................................................................................................
- Palpasi : ............................................................................................................................
- Lochea/perdarahan : ...........................................................................................................
- Keadaan rektum : ...............................................................................................................
- Keluhan : ............................................................................................................................
h. Pemeriksaan muskuloskeletal :
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II. DATA PENUNJANG

1. Laboratorium : .....................................................................................................................
2. NST,CST : .....................................................................................................................
3. USG : .........................................................................................................
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4. Rontgen : .....................................................................................................................
5. Terapi yang didapat : .....................................................................................................................

III. DATA TAMBAHAN

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Malang, .....................
Pemeriksa

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 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

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

PRIORITAS MASALAH
Nama klien : .............................................. Ruangan/kamar : ..............................................
Umur : .............................................. No. RM : ..............................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat
 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)