FORMAT ASUHAN KEPERAWATAN MATERNITAS (OBSTETRI)

STIKes BINA SEHAT PPNI KAB. MOJOKERTO

PENGKAJIAN
Tanggal MRS : ........................................................
Ruang : ........................................................
No. Register : ........................................................
Diagnosa Medis : ........................................................
Tanggal Pengkajian : ...........................................................

A. IDENTITAS PASIEN:
- Nama : ........................................................
- Umur : ........................................................
- Suku/Bangsa: ....................................................
- Bahasa : ........................................................
- Pekerjaan : ........................................................
- Status : ........................................................
- Alamat : ........................................................
- Nama Suami: .....................................................
- Pekerjaan : ........................................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA
……………………………………………………………………………………….

2. RIWAYAT KESEHATAN SEKARANG

……………………………………………………………………………………….
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3. RIWAYAT PENYAKIT DAHULU
……………………………………………………………………………………….
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4. RIWAYAT PENYAKIT KELUARGA

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1 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 5. Riwayat Obstetri
Riwayat Kehamilan Sekarang : G.................P................A...............
HPHT : ............................................................................

Gerakan janin : ............................................................................

Keluhan tiap trimester :..........................................................................

... ......................................................................

...........................................................................

Riwayat nifas : ............................................................................

............................................................................

Imunisasi TT : ............................................................................

Obat yang dikonsumsi : Obat (................................................................)

Jamu (................................................................)

6. Riwayat Haid
Menarche : …………………………………………

Siklus : …………………………………………

Lamanya : …………………………………………

Banyaknya : …………………………………………

Desmenorhoe : …………………………………………

7. Riwayat Kehamilan, nifas dan persalinan yang lalu

Hamil Ke Tgl Usia Jenis Penolong Penyulit Anak Nifas
Kehamilan kehamilan &
Partus partus Persalianan JK BB PB ASI Penyulit

2 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 8. Riwayat Ginekologi
Infertilitas : ....................................................................................................

Masa : ....................................................................................................

Penyakit : ....................................................................................................

Operasi : ....................................................................................................

9. Riwayat KB
Kontrasepsi yang dipakai : ............................................................................

Keluhan : ……………………………………………........

Kontrasepsi yang lalu : …………………………………………............

Lamanya pemakaian : ……………………………………………........

Alasan berhenti : ............................................................................

10. Pola Gordon ( 11 atau sesuai dengan kondisi klien )

PEMERIKSAAN FISIK
1. Kesadaran
(__) Komposmentis

(__) Somnolent

(__) Sopor

(__) Sopor komatus

(__) Komatus

2. Tanda-tanda Vital
Nadi ……………X/mnt

Suhu …………...X/mnt

Tensi …………..mmHg

Respirasi ……….X/mnt

3. Kepala
Rambut : …………………………………………………………………

3 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 Mata : Konjungtiva : …………………………………………………

Sclera : …………………………………………………

Pengelihatan : …………………………………………………

Telinga : …………………………………………………………………

Hidung : …………………………………………………………………

Mulut : …………………………………………………………………

Leher : …………………………………………………………………

4. Thorax
Dada : Bentuk simetri : Ya (__) Tidak (__)

Mamae : Bentuk simetris : Ya (__) Tidak (__)

Puting Susu : ………………………………………....

Benjolan : …………………………………………

Ekskresi : …………………………………………

Paru-paru : …………………………………………………………………

Jantung : …………………………………………………………………

5. Abdomen
Inspeksi: Bentuk : …………………………………………………

Striae : ……………………………………....................

Bekas luka Operasi : ………………………………..................

Palpasi : Tinggi Fundus Uteri : ………… …Cm

Lingkar Perut : .................... Cm

Posisi Janin : Leopold I : ……………………………………...

Leopold II : ……………………………………..

Leopold III :…………………………………….

Leopold IV : ……………………………………

Kontraksi Uterus : frekuensi :……………………………….

Interval : ……………………………...

4 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 Intensitas : ……………………………

Auskultasi DJJ : .............................................................................................

6. Genetalia Luar
Bentuk : …………………………………………………………………

Varices : …………………………………………………………………

Oedema : …………………………………………………………………

Massa / Kista : ....................................................................................................

Pengeluaran pervigam : .......................................................................................

7. Ekstremitas (tangan & kaki)

Bentuk : Kaki : ................................. Tangan : .......................................

Kuku : Kaki : ................................ Tangan : .......................................

Refleks Patela : ................................

Oedema : ................................

8. Kulit
Warna : ....................................

Turgor : ....................................

DATA PENUNJANG (LABORATORIUM)

a. Pemeriksaan urine
Protein : .........................................

Reduksi : .........................................

b. Pemeriksaan darah
Hb : .............................

Golongan darah : .............................

c. Pemeriksaan lain-lain bila diperlukan

.....................................................................................................................

.....................................................................................................................

TERAPI
……………………………………………………………………………………….
……………………………………………………………………………………….

5 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 ANALISA DATA

Nama Pasien: No. Reg:

NO
DATA ETIOLOGI MASALAH TTD
Dx

6 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 DAFTAR DIAGNOSIS

Nama Pasien: No. Reg:

NO DIAGNOSIS KEPERAWATAN TTD

7 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 RENCANA KEPERAWATAN

Nama Pasien: No. Reg:

TUJUAN &
NO
KRITERIA INTERVENSI RASIONAL
Dx
HASIL

8 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 EVALUASI KEPERAWATAN

Nama Pasien: No. Reg:

NO EVALUASI TTD
Dx S-O-A-P
1

9 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 FORMAT RESUME KEPERAWATAN MATERNITAS

Nama Preseptee :
NIM :
Tempat Praktek :
Tanggal :

A. Identitas Klien
Nama : ………………………….. L/P
Tempat & Tgl lahir : ....................................... Gol Darah : O / A / B / AB
Pendidikan Terakhir : ....................................................................................
Agama : ....................................................................................
Status perkawinan : ....................................................................................
Pekerjaan : ....................................................................................
TB/BB : ……….. cm/ …… kg
Alamat : ....................................................................................
.............................................................................................................................
Tanggal Pengkajian :......................................................................................

B. RESUME KEPERAWATAN
NO PROBLEM IMPLEMENTASI EVALUASI
1 DS :
DO :
DX :

2 DS :
DO :
DX :

3 DS :
DO :
DX :

...............................,.................................2018
Preseptee (preseptee)Ners,

(............................................)

10 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 FORMAT ASUHAN KEPERAWATAN MATERNITAS (GINEKOLOGI)
STIKes BINA SEHAT PPNI KAB. MOJOKERTO

I. PENGKAJIAN
Tanggal MRS : ........................................................
Ruang : ........................................................
No. Register : ........................................................
Diagnosa Medis : ........................................................
Tanggal Pengkajian : ...........................................................

A. IDENTITAS PASIEN:
- Nama : ........................................................
- Umur : ........................................................
- Suku/Bangsa: ....................................................
- Bahasa : ........................................................
- Pekerjaan : ........................................................
- Status : ........................................................
- Alamat : ........................................................
- Nama Suami: .....................................................
- Pekerjaan : ........................................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA
……………………………………………………………………………………….

2. RIWAYAT PENYAKIT SEKARANG

……………………………………………………………………………………….
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3. RIWAYAT PENYAKIT DAHULU
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4. RIWAYAT PENYAKIT KELUARGA
……………………………………………………………………………………….
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11 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 KEADAAN UMUM :
Tanda-tanda vital: Nadi : _____ SUHU : _____ RR : _____ TD: ________

II. PENGKAJIAN SISTEM

1. B1 (BREATING)
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2. B2 (BLOOD)
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3. B3 (BRAIN)
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4. B4 (BLADDER)
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12 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 5. B5 (BOWEL)
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6. B6 (BONE)
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III. PEMERIKSAAN PENUNJANG
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IV. TERAPI
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13 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 ANALISA DATA

Nama Pasien: No. Reg:

NO
DATA ETIOLOGI MASALAH TTD
Dx

14 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 DAFTAR DIAGNOSIS

Nama Pasien: No. Reg:

NO DIAGNOSIS KEPERAWATAN TTD

15 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 RENCANA KEPERAWATAN

Nama Pasien: No. Reg:

TUJUAN &
NO
KRITERIA INTERVENSI RASIONAL
Dx
HASIL

16 | Form Keperawatan Maternitas Praktik S1-Keperawatan

 EVALUASI KEPERAWATAN

Nama Pasien: No. Reg:

NO EVALUASI TTD
Dx S-O-A-P
1

17 | Form Keperawatan Maternitas Praktik S1-Keperawatan