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

Anak Tanggal U Jenis Tempat Komplikasi Bayi Nifas
Ke- Lahir/Umur K Persalinan Persalinan Penolong Bayi Ibu PB/BB Keadaan Keadaan laktasi
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 : ......................................................................................................................
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: .........................

 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 :
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

Penolong
Ke- Lahir/Umur K Persalinan Persalinan Bayi Ibu PB/BB Keadaan Keadaan laktasi
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 : ......................................................................................................................
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 : ...........................................................................................
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

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 : ......................................................................................................................
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 : ..............................................................................

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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:

12. ACTIVITY DAILY LIVING

8. Tangan dan Kaki

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

2. Alasan Utama Masuk Kamar Bersalin:

7. Riwayat Kehamilan Sekarang

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

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

7. Riwayat Kesehatan Sekarang/yang Lalu

8. Riwayat Operasi Abdomen/SC

9. Riwayat Penyakit Keluarga:

11. Riwayat Sosial Ekonomi & Psikologis

12. Riwayat Psikososial

8. Tangan dan Kaki

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

2. Riwayat Kesehatan Ibu

3. Riwayat Penyakit Keluarga

4. Riwayat Persalinan Sekarang

k. Tangan dan Kaki

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

A. DATA UMUM KLIEN

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