Form Pengkajian Maternitas

ASUHAN KEPERAWATAN PADA IBU HAMIL
Tanggal Kunjungan : ............................................................ Jam : ........................WIB

Ruang : ...............................................................................................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
IBU : ............................................... PENANGGUNG JAWAB
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Suku/Bangsa : ............................................... Suku/Bangsa : ....................................
Pendidikan : ............................................... Pendidikan : ....................................
Pekerjaan : ............................................... Pekerjaan : ....................................
Alamat : ............................................... Alamat : ....................................
2. Keluhan Utama :
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
3. Riwayat Penyakit Sekarang :

…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
4. Riwayat Menstruasi
 Menarche : .......................................................... th
 Siklus : .......................................................... hari, teratur/tidak
 Lama menstruasi : .......................................................... hari
 Banyaknya ganti pembalut : .......................................................... kali/hari
 Dismenorea/tidak : ..........................................................
5. Riwayat kehamilan, persalinan dan nifas yang lalu

Ana Tanggal U Jenis Tempat Komplikasi Bayi Nifas
k Lahir/Umu K Persalinan Persalinan Penolon Bayi Ibu PB/BB Keadaan Keadaan laktasi
Ke- r g
6. Riwayat Kehamilan Sekarang

 G P A
 HPHT : ...............................................................
 Usia Kehamilan : ...............................................................
 Kunjungan ANC: teratur/tidak, frekuensi: kali
 Tempat ANC : ...............................................................
 Obat yang biasa dikonsumsi selama hamil : ...............................................................
 Gerakan Janin : ................................. kali/hari
 Pergerakan janin pertama………….kali pada usia kehamilan……………
 Imunisasi Toxoid Tetanus sebanyak………kali yaitu:
TT 1 : ...............................................................
TT I : ...............................................................
 Tanda-tanda bahaya : ...............................................................
 Tanda-tanda persalinan : ...............................................................
7. Riwayat Kesehatan Sekarang/yang Lalu

 Jantung : .......................................................................................................
 Hipertensi : .......................................................................................................
 Diabetes Melitus : .......................................................................................................
 Ginjal : .......................................................................................................
 Asma : .......................................................................................................
 Hepatitis : .......................................................................................................
 Lain-lain : .......................................................................................................
8. Riwayat Operasi Abdomen/SC

 Tempat : .......................................................................................................
 Penolong : .......................................................................................................
 Tanggal : .......................................................................................................
9. Riwayat Penyakit Keluarga:

 Jantung : .................................................................................................
 Hipertensi : .................................................................................................
 Diabetes Melitus : .................................................................................................
 Hepatitis : .................................................................................................
 Asma : .................................................................................................
 Ginjal : .................................................................................................
 Riwayat bayi kembar : .................................................................................................
10. Riwayat KB
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
11. Riwayat Sosial Ekonomi & Psikologis

 Status Perkawinan : Kawin:………kali
 Lama menikah………….tahun
 Umur menikah pertama kali;……………..tahun
 Kehamilan ini direncanakan/Tidak direncanakan:
 Perasaan ibu dan keluarga terhadap kehamilan:
 Pengambilan keputusan dalam keluarga:
 Tempat dan petugas yang diinginkan untuk membantu persalinan:
 Tempat rujukan jika terjadi komplikasi:
 Persiapan menjelang persalinan:
12. ACTIVITY DAILY LIVING

a. Pola makan & minum
Frekuensi : ............................................................................ kali sehari
Jenis : ..................................................................................................
Porsi : ..................................................................................................
Keluhan/Pantangan : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
BAK………kali/hari, konsistensi…………….., warna………………….
BAB………kali/hari, warna………………….., lendir darah:……………
d. Personal Hygiene
Mandi : ....................................................... kali sehari
Ganti pakaian dan pakaian dalam : ....................................................... kali sehari
e. Aktifitas
Pekerjaan sehari-hari : .................................................................................................
Keluhan : .................................................................................................
Hubungan seksual : ........................................................................... kali/minggu
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum-minuman keras : ...........................................................................................
Konsumsi obat terlarang : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
1. Keadaan Umum : ........................................................................................................
Tingkat Kesadaran : ........................................................................................................
2. Tanda-tanda vital:
Tekanan darah : .................................................................. mmHg
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Respiras : .................................................................. kali/menit
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
Kenaikan BB selama hamil : .................................................................. kg
LILA : .................................................................. cm
3. Pemeriksaan Fisik
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Muka : cloasma: oedeme:
Hidung : polip:
Gigi dan mulut : ............................................................................................
4. Leher
Pembesaran kelenjar tyroid : ............................................................................................
5. Payudara
Bentuk simetris : ............................................................................................
Keadaan putting susu : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
6. Abdomen
Pembesaran perut sesuai dengan usia kehamilan/tidak
Linea nigra : ............................................................................................
Bekas luka/operasi : ............................................................................................
7. Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pembesaran Kelenjar bartholini
Pengeluaran pervaginam : ........................................................................................
Bekas luka/jahitan perineum : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
8. Tangan dan Kaki

Simetris/tidak : ............................................................................................
Odeme pada tungkai bawah : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
PALPASI
Payudara
Colostrum : .....................................................................................................................
Benjolan : .....................................................................................................................
Abdomen
TFU : .................................................................. cm
Leopold I : ...............................................................................
Leopold II : ...............................................................................
Leopold III : ...............................................................................
Leopold IV : ...............................................................................
Taksiran Berat Badan Janin ( TBJ ) : ...............................................................................
Kontraksi: kali/10mnt. Lama….detik, kuat/lemah, teratur/tidak
Kandung Kemih : ...............................................................................
AUSKULTASI
DJJ : ...............................................................................
Frekuensi : ..................................... kali/menit, teratur/tidak
Punctum maksimum : ...............................................................................
PEMERIKSAAN PANGGUL
Lingkar panggul : ...............................................................................................
Distansia cristarum : ...............................................................................................
Distansia spinarum : ...............................................................................................
Conjungata Bourdeloque : ...............................................................................................
PEMERIKSAAN DALAM
Atas indikasi:.................................... Pukul: ....................... Oleh:....................................
Dinding vagina : ..........................................................................................
Portio : ..........................................................................................
Pembukaan servik : ..........................................................................................
Konsistensi : ..........................................................................................
Ketuban : ..........................................................................................
Presentasi Fetus : ..........................................................................................
Posisi : ..........................................................................................
Penurunan Bagian Terendah : ..........................................................................................
PEMERIKSAAN PENUNJANG
Tanggal : ........................................... Jenis Pemeriksaan: ..........................................
Hasil : ........................................................................................................................
II. ANALISA DATA
III. DIAGNOSA KEPERAWATAN
IV. RENCANA TINDAKAN KEPERAWATAN
V. IMPLEMENTASI
VI. EVALUASI
ASUHAN KEPERAWATAN PADA IBU BERSALIN
Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

Jam Masuk : .......................................... Jam Pengkajian : ....................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama Suami : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Utama Masuk Kamar Bersalin:
 Menarche : .......................................................... th
4. Tanda-Tanda Persalinan
 Kontraksi:........................... Sejak tanggal: ......................... Pukul: .........................
 Frekuensi : ..........................................................
 Lamanya:........................... kekuatannya ....................................
 Lokasi ketidaknyamanan : ..........................................................
5. Pengeluaran Pervaginam
 Darah lendir : ....................... Ada/tidak, Jumlah:............. Warna: .........................
 Air Ketuban : ....................... Ada/tidak, Jumlah: ............ Warna: .........................
 Darah : ....................... Ada/tidak, Jumlah:............. Warna:..........................

Ke- r g
 G P A
 HPHT : ...............................................................
 Usia Kehamilan : ...............................................................
 Tempat ANC : ...............................................................
TT 1 : ...............................................................
TT I : ...............................................................

 Jantung : .......................................................................................................
 Hipertensi : .......................................................................................................
 Ginjal : .......................................................................................................
 Asma : .......................................................................................................
 Hepatitis : .......................................................................................................
 Lain-lain : .......................................................................................................

 Tempat : .......................................................................................................
 Penolong : .......................................................................................................
 Tanggal : .......................................................................................................

 Jantung : .................................................................................................
 Hipertensi : .................................................................................................
 Hepatitis : .................................................................................................
 Asma : .................................................................................................
 Ginjal : .................................................................................................
11. Riwayat KB :
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………

 Kehamilan ini direncanakan/Tidak direncanakan
 Perasaan ibu dan keluarga terhadap kehamilan
 Pengambilan keputusan dalam keluarga…………….
 Tempat dan petugas yang diinginkan untuk membantu persalinan:
 Tempat rujukan jika terjadi komplikasi
 Persiapan menjelang persalinan

Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Aktifitas
Keluhan : .................................................................................................
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
1. Keadaan Umum : ........................................................................................................
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Respirasi : .................................................................. kali/menit
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Muka: cloasma: oedeme:
Hidung: polip:
Gigi dan mulut : ............................................................................................
4. Leher
5. Payudara
Bentuk simetris : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
6. Abdomen
Linea nigra : ............................................................................................
9. Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pengeluaran pervaginam : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
10. Tangan dan Kaki

Simetris/tidak : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
PALPASI
Payudara
Colostrum : .....................................................................................................................
Benjolan : .....................................................................................................................
Abdomen
TFU : .................................................................. cm
Leopold I : ...............................................................................
Leopold II : ...............................................................................
Leopold III : ...............................................................................
Leopold IV : ...............................................................................
Taksiran Berat Badan Janin ( TBJ ) : ...............................................................................
Kontraksi: kali/10mnt. Lama….detik, kuat/lemah, teratur/tidak
Kandung Kemih : ...............................................................................
AUSKULTASI
DJJ : ...............................................................................
Frekuensi : ..................................... kali/menit, teratur/tidak
Punctum maksimum : ...............................................................................
PEMERIKSAAN PANGGUL
Lingkar panggul : ...............................................................................................
Distansia cristarum : ...............................................................................................
Distansia spinarum : ...............................................................................................
Conjungata Bourdeloque : ...............................................................................................
PEMERIKSAAN DALAM
Atas indikasi:.................................... Pukul: ....................... Oleh:....................................
Dinding vagina : ..........................................................................................
Portio : ..........................................................................................
Pembukaan servik : ..........................................................................................
Konsistensi : ..........................................................................................
Ketuban : ..........................................................................................
Presentasi Fetus : ..........................................................................................
Posisi : ..........................................................................................
Penurunan Bagian Terendah : ..........................................................................................
Hasil : ........................................................................................................................
KALA II
Subyektif :
Obyektif :
Assesment :
Planning :
KALA III
Subyektif :
Obyektif :
Assesment :
Planning :
KALA IV
Subyektif :
Obyektif :
Assesment :
Planning :
II. ANALISA DATA
V. IMPLEMENTASI KEPERAWATAN
VI. EVALUASI
VII. CATATAN PERKEMBANGAN

ASUHAN KEPERAWATAN PADA IBU NIFAS

Tempat : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Utama/Alasan Masuk:

…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
 Menarche : .......................................................... th

Penolon
k Lahir/Umu K Persalinan Persalinan Bayi Ibu PB/BB Keadaan Keadaan laktasi
g
Ke- r
5. Riwayat Persalinan Sekarang

 Tanggal/Jam Persalinan : ...........................................................................................
 Tempat Persalinan : ...........................................................................................
 Penolong Persalinan : ...........................................................................................
 Jenis Persalinan : ...........................................................................................
 Komplikasi Persalinan : ...........................................................................................
 Keadaan Plasenta : ...........................................................................................
 Tali Pusat : ...........................................................................................
 Lama Persalinan : Kala I ........ Kala II ......... Kala III ........... Kala IV ............
 Jumlah Perdarahan : BB: ............ PB: ............. Apgar Score: .............
 Bayi : BB: ............ PB: ............. Apgar Score: .............
Cacat Bawaan: ............... Cacat Bawaan: .................
Masa Gestasi: ................ minggu

 G P A
 HPHT : ...............................................................
 Usia Kehamilan : ...............................................................
 Tempat ANC : ...............................................................
TT 1 : ...............................................................
TT I : ...............................................................
 Jantung : .......................................................................................................
 Hipertensi : .......................................................................................................
 Ginjal : .......................................................................................................
 Asma : .......................................................................................................
 Hepatitis : .......................................................................................................
 Lain-lain : .......................................................................................................

 Tempat : .......................................................................................................
 Penolong : .......................................................................................................
 Tanggal : .......................................................................................................

 Jantung : .................................................................................................
 Hipertensi : .................................................................................................
 Hepatitis : .................................................................................................
 Asma : .................................................................................................
 Ginjal : .................................................................................................
10. Riwayat KB
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………

 Kehamilan ini direncanakan/Tidak direncanakan
 Perasaan ibu dan keluarga terhadap kehamilan
 Pengambilan keputusan dalam keluarga…………….
12. Riwayat Psikososial

 Taking In : ..............................................................................................................
 Taking Hold : ..............................................................................................................
 Letting Go : ..............................................................................................................
Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Mobilisasi
………………………………………………………………………………………………………
…………………………………………………………………………………………………
f. Aktifitas
Keluhan : .................................................................................................
g. Menyusui
Keluhan : .................................................................................................
h. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
1. Keadaan Umum : ........................................................................................................
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Mata: conjungtiva: sklera:
Hidung: polip:
Gigi dan mulut : ............................................................................................
4. Leher
5. Payudara
Bentuk simetris : ............................................................................................
Aerola mamae : ............................................................................................
Colostrum : ............................................................................................
6. Abdomen
Linea nigra : ............................................................................................
7. Genetalia
Varises : ........................................................................................
Odema : ........................................................................................
Pengeluaran pervaginam : ..................................... Lochea: ................................
Bau : ........................................................................................
Anus : ........................................................................................
Haemoroid/tidak : ........................................................................................
8. Tangan dan Kaki

Simetris/tidak : ............................................................................................
Varises : ............................................................................................
Pergerakan : ............................................................................................
Hasil : ........................................................................................................................
II. ANALISA DATA
V. IMPLEMENTASI
VI. EVALUASI
ASUHAN KEPERAWATAN PADA BAYI BARU LAHIR

Tempat : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Identitas Pasien
PASIEN : .............................................. PENANGGUNG JAWAB
Nama : .............................................. Nama : ....................................
Umur : .............................................. Umur : ....................................
Tgl./Jam Lahir : .............................................. Agama : ....................................
Jenis Kelamin : .............................................. Suku/Bangsa : ....................................
BB Lahir : .............................................. Pendidikan : ....................................
Panjang Badan : .............................................. Pekerjaan : ....................................
.............................................. Alamat : ....................................
2. Riwayat Kesehatan Ibu

 Jantung : ..................................................................................................
 Hipertensi : ..................................................................................................
 Diabetes Melitus : ..................................................................................................
 Ginjal : ..................................................................................................
 Asma : ..................................................................................................
 Hepatitis : ..................................................................................................
 Riwayat Operasi/SC : ..................................................................................................
3. Riwayat Penyakit Keluarga
 Jantung : ...............................................................................................
 Hipertensi : ...............................................................................................
 Diabetes Melitus : ...............................................................................................
 Hepatitis : ...............................................................................................
 Asma : ...............................................................................................
 Ginjal : ...............................................................................................
 Riwayat Bayi Kembar : ...............................................................................................
4. Riwayat Persalinan Sekarang

 G P A
 Usia Kehamilan :
 Tanggal/Jam Persalinan : ...........................................................................................
 Tempat Persalinan : ...........................................................................................
 Penolong Persalinan : ...........................................................................................
 Jenis Persalinan : ...........................................................................................
 Komplikasi Persalinan : ...........................................................................................
Pada Ibu : ...........................................................................................
Pada Bayi : ...........................................................................................
 Ketuban Pecah : ...........................................................................................
 Keadaan Plasenta : ...........................................................................................
 Tali Pusat : ...........................................................................................
 Lama Persalinan : Kala I ........ Kala II ......... Kala III ........... Kala IV ............
 Jumlah Perdarahan : BB: ............ PB: ............. Apgar Score: .............
 Selama Operasi : ...........................................................................................
5. Riwayat Kehamilan
 Riwayat Komplikasi Kehamilan
Perdarahan : ...............................................................................................
Preeklampsi/Eklampsi : ...............................................................................................
Penyakit Kelamin : ...............................................................................................
Lain-Lain : ...............................................................................................
 Kebiasaan Ibu Waktu Hamil
Makanan : ...............................................................................................
Obat-Obatan : ...............................................................................................
Jamu : ...............................................................................................
Merokok : ...............................................................................................
B. Data Objektif
1. Kebutuhan Bayi
 Intake : ..................................................................................................
 Eliminasi : ..................................................................................................
 Miksi : ..................................................................................................
 Keluar Tanggal : ..................................................................................................
 Mekonium : ..................................................................................................
 Warna : ..................................................................................................
 Keluar Tanggal : ..................................................................................................
 Aktifitas : ..................................................................................................
2. Antropometri
 Berat Badan : ..................................................................................................
 Panjang Badan : ..................................................................................................
 Lingkar Kepala : ..................................................................................................
 Lingkar Dada : ..................................................................................................
 Lingkar perut : ..................................................................................................
3. Pemeriksaan Umum
 Jenis kelamin : ...............................................................................................
 APGAR Score : ...............................................................................................
 Keadaan Umum Bayi : ...............................................................................................
 Suhu : ...............................................................................................
 Bunyi jantung : ...............................................................................................
 Frekuensi : ...............................................................................................
 Respirasi : ...............................................................................................
a. Kepala
 Fontanel anterior : ............................................................................................
 Sutura sagitalis : ............................................................................................
 Caput succedanum : ............................................................................................
 Cepal hematom : ............................................................................................
b. Mata
 Letak : ............................................................................................
 Bentuk : ............................................................................................
 Sekret : ............................................................................................
 Conjungtiva : ............................................................................................
 Sklera : ............................................................................................
c. Hidung
 Bentuk : ............................................................................................
 Sekret : ............................................................................................
d. Mulut
 Bibir : ............................................................................................
 Palatum : ............................................................................................
e. Telinga
 Bentuk : ............................................................................................
 Simetris : ............................................................................................
 Sekret : ............................................................................................
f. Leher
 Pergerakan : ............................................................................................
 Pembengkakan : ............................................................................................
 Kekakuan : ............................................................................................
g. Dada
 Bentuk : ............................................................................................
 Retrksi dinding dada : ............................................................................................
h. Paru-paru
 Suara nafas : ............................................................................................
 Respirasi : ............................................................................................
i. Abdomen
 Peristaltik usus : ............................................................................................
 Tali pusat : ............................................................................................
j. Punggung
………………………………………………………………………………………………………
…………………………………………………………………………………………………
……………………………………………………………………………………………………
k. Tangan dan Kaki

 Gerakan : ............................................................................................
 Bentuk : ............................................................................................
 Jumlah : ............................................................................................
 Warna : ............................................................................................
l. Reflek
 Reflek moro : ............................................................................................
 Reflek rooting : ............................................................................................
 Reflek sucking : ............................................................................................
 Reflek walking : ............................................................................................
 Reflek tonic neck : ............................................................................................
 Reflek babinski : ............................................................................................
 Reflek graping : ............................................................................................
m. Pemeriksaan Penunjang
 Tanggal : ............................................................................................
 Jenis Pemeriksaan : ............................................................................................
 Hasil : ............................................................................................
II. ANALISA DATA
V. IMPLEMENTASI
VI. EVALUASI
ASUHAN KEPERAWATAN PADA AKSEPTOR KB……
Tanggal Kunjungan : .......................................... Jam : .................................. WIB

Ruang : ..........................................
I. PENGKAJIAN
A. Data Subjektif
1. Biodata
Nama : ............................................... Nama : ....................................
Umur : ............................................... Umur : ....................................
Agama : ............................................... Agama : ....................................
Alamat : ............................................... Alamat : ....................................
2. Alasan Kunjungan
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………
 Menarche : .......................................................... th

Ke- r g
5. Riwayat Kesehatan/Penyakit Sekarang/yang Lalu

 Jantung : ..................................................................................
 Hipertensi : ..................................................................................
 Diabetes Melitus : ..................................................................................
 Ginjal : ..................................................................................
 Asma : ..................................................................................
 Hepatitis : ..................................................................................
 HIV/AIDS : ..................................................................................
 Riwayat Operasi Abdomen/SC : ..................................................................................

 Jantung : .................................................................................................
 Hipertensi : .................................................................................................
 Hepatitis : .................................................................................................
 Asma : .................................................................................................
 Ginjal : .................................................................................................
7. Riwayat KB
…………………………………………………………………………………………………………
…………………………………………………………………………………………………....
………………………………………………………………………………………………………

 Respon Ibu/Suami terhadap pemakaian
 Pengambilan keputusan dalam keluarga alat kontrasepsi

Jenis : ..................................................................................................
Porsi : ..................................................................................................
b. Pola Istirahat
Tidur siang : ............................................................................ jam
Tidur malam : ............................................................................ jam
Keluhan : ............................................................................ jam
c. Pola eliminasi
d. Personal Hygiene
e. Aktifitas
Keluhan : .................................................................................................
f. Kebiasaan hidup
Merokok : ...........................................................................................
Minum jamu : ...........................................................................................
B. Data Objektif
1. Keadaan Umum : ........................................................................................................
Nadi : .................................................................. kali/menit
Suhu : ............................................................................................
Tinggi badan : .................................................................. cm
Berat badan : .................................................................. kg
LILA : .................................................................. cm
Inspeksi : ............................................................................................
Postur Tubuh : ............................................................................................
Kepala : ............................................................................................
Rambut : ............................................................................................
Hidung: polip:
Gigi dan mulut : ............................................................................................
4. Leher
5. Payudara
Bentuk simetris : ............................................................................................
Ada Benjolan atau Tidak : ............................................................................................
6. Abdomen
Inspeksi : ............................................................................................
Palpasi : ............................................................................................
7. Genetalia
Varises : ........................................................................................
8. Anus
Heaemoroid/tidak : ........................................................................................
9. Ekstremitas (Tangan dan Kaki)

Simetris/tidak : ........................................................................................
Oedeme pada Tungkai Bawah : ........................................................................................
Varises : ........................................................................................
Pergerakan : ........................................................................................
10. Pemeriksaan Penunjang

Hasil : ........................................................................................................................
II. ANALISA DATA

V. IMPLEMENTASI
VI. EVALUASI
KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN MALANG
PROGRAM STUDI D-IV KEPERAWATAN MALANG
FORMAT PENGKAJIAN GANGGUAN REPRODUKSI
Askep : ..............................................................................................................
: ..............................................................................................................
Tanggal Pengkajian : ..............................................................................................................
Ruang/RS : ..............................................................................................................
A. DATA UMUM KLIEN

1. Nama Klien : .................................................................................................
2. Usia : .................................................................................................
3. Agama : .................................................................................................
4. Status perkawinan : .................................................................................................
5. Pekerjaan : .................................................................................................
6. Pendidikan Terakhir : .................................................................................................
7. Nama suami : .................................................................................................
8. Umur : .................................................................................................
9. Agama : .................................................................................................
10. Pekerjaan : .................................................................................................
11. Pendidikan terakhir : .................................................................................................
12. Alamat : .................................................................................................
B. ANAMNESE
1. Diagnosa Medis : ....................................................................................
2. Keluhan Utama : ....................................................................................
3. Keluhan Saat pengkajian : ....................................................................................
4. Riwayat penyakit Sekarang : ....................................................................................
5. Riwayat penyakit yang lalu : ....................................................................................
6. Riwayat kesehatan keluarga : ....................................................................................
7. Riwayat menstruasi
a. Menarche : ..................................... Umur: ..................... th
b. Siklus : ...............................................................................................
c. Jumlah : ...............................................................................................
d. Lamanya : ...............................................................................................
e. Keteraturan : ...............................................................................................
f. Dsmenorhea : ...............................................................................................
g. Masalah Khusus : ...............................................................................................
8. Riwayat Perkawinan
a. Status perkawinan : ..............................................................................................
b. Dengan suami : ..............................................................................................
c. Lama perkawinan : ..............................................................................................
9. Riwayat KB : ....................................................................................
10. Pola Aktifitas sehari-hari
a. Makan dan minum : ........................................................................................
b. Pola eliminasi : ........................................................................................
c. Pola istirahat dan tidur : ........................................................................................
d. Kebersihan diri : ........................................................................................
11. Riwayat Psikososial : ....................................................................................
C. PEMERIKSAAN FISIK
1. Keadaan Umum : ...............................................................................
2. Tanda vital : ...............................................................................
3. Pemeriksaan Kepala dan leher : ...............................................................................
4. Dada dan thorax : ...............................................................................
5. Payudara : ...............................................................................
6. Abdomen : ...............................................................................
7. Genetalia : ...............................................................................
8. Extremitas : ...............................................................................
9. Pemeriksaan neurologis : ...............................................................................
10. Pemeriksaan Penunjang : ...............................................................................
11. Terapi/penatalaksanaan : ...............................................................................
D. ANALISA DATA
E. DIAGNOSA KEPERAWATAN
F. RENCANA KEPERAWATAN
G. IMPLEMENTASI KEPERAWATAN
H. EVALUASI
I. CATATAN PERKEMBANGAN

Form Pengkajian Maternitas

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Hak Cipta

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Format Tersedia

Form Pengkajian Maternitas

Diunggah oleh

Hak Cipta:

Format Tersedia

ASUHAN KEPERAWATAN PADA IBU HAMIL

Tanggal Kunjungan : ............................................................ Jam : ........................WIB

3. Riwayat Penyakit Sekarang :

5. Riwayat kehamilan, persalinan dan nifas yang lalu

6. Riwayat Kehamilan Sekarang

7. Riwayat Kesehatan Sekarang/yang Lalu

8. Riwayat Operasi Abdomen/SC

9. Riwayat Penyakit Keluarga:

11. Riwayat Sosial Ekonomi & Psikologis

12. ACTIVITY DAILY LIVING

8. Tangan dan Kaki

III. DIAGNOSA KEPERAWATAN

IV. RENCANA TINDAKAN KEPERAWATAN

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Alasan Utama Masuk Kamar Bersalin:

6. Riwayat kehamilan, persalinan dan nifas yang lalu

8. Riwayat Kesehatan Sekarang/yang Lalu

9. Riwayat Operasi Abdomen/SC

10. Riwayat Penyakit Keluarga:

12. Riwayat Sosial Ekonomi & Psikologis

13. ACTIVITY DAILY LIVING

10. Tangan dan Kaki

II. ANALISA DATA

III. DIAGNOSA KEPERAWATAN

IV. RENCANA TINDAKAN KEPERAWATAN

VII. CATATAN PERKEMBANGAN

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Alasan Utama/Alasan Masuk:

4. Riwayat kehamilan, persalinan dan nifas yang lalu

5. Riwayat Persalinan Sekarang

6. Riwayat Kehamilan Sekarang

8. Riwayat Operasi Abdomen/SC

9. Riwayat Penyakit Keluarga:

11. Riwayat Sosial Ekonomi & Psikologis

12. Riwayat Psikososial

8. Tangan dan Kaki

II. ANALISA DATA

III. DIAGNOSA KEPERAWATAN

IV. RENCANA TINDAKAN KEPERAWATAN

VII. CATATAN PERKEMBANGAN

ASUHAN KEPERAWATAN PADA BAYI BARU LAHIR

Tanggal Masuk : .......................................... Tanggal Pengkajian : ....................................

2. Riwayat Kesehatan Ibu

4. Riwayat Persalinan Sekarang

k. Tangan dan Kaki

II. ANALISA DATA

III. DIAGNOSA KEPERAWATAN

IV. RENCANA TINDAKAN KEPERAWATAN

Tanggal Kunjungan : .......................................... Jam : .................................. WIB

4. Riwayat kehamilan, persalinan dan nifas yang lalu

5. Riwayat Kesehatan/Penyakit Sekarang/yang Lalu

6. Riwayat Penyakit Keluarga:

8. Riwayat Sosial Ekonomi & Psikologis

9. ACTIVITY DAILY LIVING

9. Ekstremitas (Tangan dan Kaki)

10. Pemeriksaan Penunjang

II. ANALISA DATA

FORMAT PENGKAJIAN GANGGUAN REPRODUKSI

A. DATA UMUM KLIEN

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