FORMAT ASUHAN KEPERAWATAN MATERNITAS

“ INTRANATAL “

ASUHAN KEPERAWATAN PADA Ny.................. DENGAN

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DI RUANG ..........................RS ………………………..
PADA TANGGAL ..................................................................

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :

Umur :

Pendidikan :

Pekerjaan :

Status Perkawinan :

Agama :

Suku :

Alamat :

No CM :

Tanggal MRS :

Tanggal Pengkajian :

Sumber informasi :

PENANGGUNG JAWAB
Nama :

Umur :

Pendidikan :

JenisKelamin :
 Pekerjaan :

Alamat :

Status
Perkawinan :

Agama :

B. DATA KESEHATAN
1. KeluhanUtama
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2. Keluhan saat dikaji

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3. Riwayat keluhan
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C. RIWAYAT OBSTETRI DAN GINEKOLOGI
1. Riwayatmenstruasi:
 Menarche :

 Banyaknya :

 Siklus : teratur ( ) tidak ( )

 Lama :

 Keluhan :

 HPHT :

2. Riwayatpernikahan
 Menikah : ……….. kali
 Lama : ……….. tahun
3. Riwayat kehamilan, persalinan, nifas yang lalu :

AnakKe Kehamilan Persalinan

No Thn Umur Penyulit jenis penolong Penyulit
kehamilan

Komplikasinifas Anak
Laserasi infeksi Perdarahan Jenis BB Pj
Kelamin
4. Riwayat kehamilan sekarang
Status Obstetrikus :
 G….. P….. A…... H…..
 UK : ………. minggu
 TP : ………..
 ANC kehamilansekarang
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Trimester I :
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Trimester II :
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Trimester III :
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5. Riwayatkeluargaberencana
 Akseptor KB :

 Jenis :

 Lama :

 Masalah :
D. RIWAYAT PENYAKIT
1. Klien
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2. Keluarga
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E. POLA FUNGSIONAL KESEHATAN

1. Pemeliharan dan persepsi terhadap kesehatan
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2. Nutrisi / metabolic
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 3. Pola eliminasi
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4. Polaaktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4

Makan / minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
Ket :
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total

5. Oksigenasi
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6. Pola tidur dan istirahat

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7. Pola perseptual
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8. Pola persepsi diri

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9. Pola seksual dan reproduksi

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10. Pola peran – hubungan

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 11. Pola manajemen koping stress
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12. Sistem nilai dan keyakinan

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G. PEMERIKSAAN FISIK
Keadaan umum:
GCS :

Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)

Tanda – tanda vital
 TD :

 Nadi :

 Suhu :

 RR :

BB :

TB :

LILA :
 Head toetoe:
1. Kepala
Wajah

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Sclera
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Konjungtiva
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Pembesaran limphe node

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Pembesaran kelenjar tiroid

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Telinga
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2. Kulit
Lineanigra :( )
Striaegravidarum :( )
Pucat :( )
Cloasma :( )
3. Dada
Payudara :
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Areola :
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Putting :
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Tanda dimpling / retraksi :

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Pengeluaran ASI :
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Paru
 Inspeksi :
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 Palpasi :
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 Perkusi :
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  Auskultasi :
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Jantung
 Inspeksi :
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 Palpasi :
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 Perkusi :
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 Auskultasi :
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4. Abdomen
Linea :
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Striae :
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Pembesaran UK :
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Gerakanjanin :
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Kontraksi :
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Luka bekasoprasi :
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Ballottement :
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Leopold I :Kepala / bokong / kosong
 TFU :
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Leopold II
 Kanan :Punggung / bagiankecil / bokong / kepala
 Kiri :Punggung / bagiankecil / bokong / kepala
Leopold III : presentasikepala / bokong / kosong
Leopold IV : Bagianmasuk PAP (konvergen / divergen / sejajar)
Penurunankepala :
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Kontraksi :
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DJJ :
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Bisingusus :
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5. Genetalia dan perineum
Kebersihan :
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Pengeluaran :
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Karakteristik :
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Hemoroid :
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Hasil VT :
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6. Ekstrimitas
Atas
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Bawah
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H. DATA PENUNJANG
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1. Diagnosamedis :

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2. Terapi
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II. ANALISA DATA KALA 1

DATA ETIOLOGI PROBLEM

 ANALISA DATA KALA 2

DATA ETIOLOGI PROBLEM

 ANALISA DATA KALA 3

DATA ETIOLOGI PROBLEM

 ANALISA DATA KALA 4

DATA ETIOLOGI PROBLEM

III. TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN
KALA 1
NO TANGGAL/ DIAGNOSA TANGGAL TTD
JAM KEPERAWATAN TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN
KALA 2
NO TANGGAL/ DIAGNOSA TANGGAL TTD
JAM KEPERAWATAN TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN
KALA 3
NO TANGGAL/ DIAGNOSA TANGGAL TTD
JAM KEPERAWATAN TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN
KALA 4
NO TANGGAL/ DIAGNOSA TANGGAL TTD
JAM KEPERAWATAN TERATASI
Ditemukan
IV. RENCANA TINDAKAN KEPERAWATAN KALA 1

No. Tgl No. RencanaKeperawatan

/ Diagnosa Tujuan Intervensi Rasional
Jam
 RENCANA TINDAKAN KEPERAWATAN KALA 2

No. Tgl No. RencanaKeperawatan

/ Diagnosa Tujuan Intervensi Rasional
Jam
 RENCANA TINDAKAN KEPERAWATAN KALA 3

No. Tgl No. RencanaKeperawatan

/ Diagnosa Tujuan Intervensi Rasional
Jam
 RENCANA TINDAKAN KEPERAWATAN KALA 4

No. Tgl No. RencanaKeperawatan

/ Diagnosa Tujuan Intervensi Rasional
Jam
V. IMPLEMENTASI KEPERAWATAN KALA 1

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal Dx.
/ Jam
IMPLEMENTASI KEPERAWATAN KALA 2

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal Dx.
/ Jam

IMPLEMENTASI KEPERAWATAN KALA 3

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal Dx.
/ Jam
 IMPLEMENTASI KEPERAWATAN KALA 4

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal Dx.
/ Jam
VI. EVALUASI KEPERAWATAN KALA 1

No. Hari / No. Evaluasi Ttd

tanggal / Dx.
Jam
 EVALUASI KEPERAWATAN KALA 2

No. Hari / No. Evaluasi Ttd

tanggal / Dx.
Jam
 EVALUASI KEPERAWATAN KALA 3

No. Hari / No. Evaluasi Ttd

tanggal / Dx.
Jam
 EVALUASI KEPERAWATAN KALA 4

No. Hari / No. Evaluasi Ttd

tanggal / Dx.
Jam