KEPERAWATAN MATERNITAS
A.
IDENTITAS
Nama Pasien : …………… Nama Suami : ……………
Umur : …………… Umur : ……………
Suku Bangsa : …………… Suku Bangsa : ……………
Agama : …………… Agama : ……………
Pendidikan : …………… Pendidikan : ……………
Pekerjaan : …………… Pekerjaan : ……………
Alamat Rumah : …………… Alamat Rumah : ……………
Status Perkawinan : …………… Status Perkawinan : ……………
C. RIWAYAT KEPERAWATAN
1. Riwayat Obstetri
a. Riwayat Menstruasi
Menarche umur ………………. Siklus ………………….
c. Genogram
d. Kehamilan Sekarang
Diagnosa Kehamilan :..........................................................
Usia Kehamilan :.............................................................................
Imunisasi:....................................................................................
ANC :..............................................................................................
Keluhan selama hamil dan keluhan saat ini :.............................
Pengobatan selama hamil :.....................................................
Pergerakkan janin ................................................................
Rencana perawatan bayi ( ) sendiri ( ) orang tua ( ) lain lain
Keterangan.......................................................................................
Kesanggupan dan pengetahuan dalam merawat bayi :.................................................
Breast care :............................................................................
Perineal care :......................................................................
Nutrisi :.....................................................................................
Senam nifas : ....................................................................
KB :......................................................................................
Menyusui : ...............................................................................
3. Riwayat Kesehatan
Penyakit yang pernah dialami Ibu ……………………………………………
Pengobatan yang didapat………………………………………
Riwayat penyakit keluarga…………………………………..
Keterangan :……………… ……………………………….
4. Riwayat Lingkungan
Kebersihan………………………………………………..
Bahaya……………………………………………………………
Lainnya. Sebutkan………………………………………..
5. Aspek Psikososial
Apakah kehamilan ini direncanakan oleh ibu dan pasangan? …………….
Harapan yang ibu inginkan selama kehamilan....................................
Bagaiman dukungan pasangan terhadap kehamilan ini
Bagaimana sikap anggota keluarga lainnya terhadap kehamilan ini.....
Lainnya. Sebutkan...............................................................................
BAB
Frekuensi ..........................................................................................
Warna................................................................................................
Bau......................................................................................................
Konsistensi.........................................................................................
Keluhan..............................................................................................
d. Pola personal hygiene
Mandi
Frekuensi.................................................................................
Keterangan .................................................................................................
Oral Hygiene
Frekuensi............................................................................................
Waktu.................................................................................................
Keterangan..........................................................................................
Cuci Rambut
Frekuensi...............................................................................................
Keterangan...............................................................................................
e. Pola istirahat dan tidur
Lama tidur...............................................
Kebiasaan sebelum tidur...............................................................
Keluhan.................................................................................................
f. Pola aktifitas dan latihan
Kegiatan dalam pekerjaan
Waktu bekerja.......................................................
Olah raga...............................................................................................
Frekuensi.............................................................................................
Kegiatan waktu luang..........................................................................
Keluhan dalam aktivitas ..........................................................................
D. PEMERIKSAAN FISIK
Keadaan umum : …………… Kesadaran ……………………
Hidung
Reaksi allergi..............................................................................
Sinus...................................................................................
Lainnya.....................................................................................
Pernapasan
Jalan napas...................................................................................
Suara napas.........................................
Penggunaan otot bantu pernapasan.................................................
Sirkulasi Jantung
Frekuensi nadi....................................................................
Irama.................................................................................................
Kelainan bunyi jantung.......................................................
Abdomen
Perineum/ vulva………………………………………
Vesika Urinaria……………………………………
Striae……………………………………………………………
Lainnya…………………………………………………………
Genital
Keputihan……………………………………………………………
Pap Smear……………………………………………
Lainnya………………………….………………………………
Ekstrimitas
Turgor kulit ……………………………………………………………..
Warna kulit ……………………………………………………………..
Kesulitan dalam pergerakkan ……………………………………………………………..
Lainnya……………………………………………………………..
E. DATA PENUNJANG
Laboratorium
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USG
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F. TERAPI
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G. DATA TAMBAHAN
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Malang, …… …………….
Perawat,
(…………………………..)