PENGKAJIAN PRENATAL

Nama mahasiswa : …………………………………….

NIM : …………………………………….
Tanggal pengkajian : …………………………………….
Ruangan/ RS/ PKM : …………………………………….
Tgl, Jam MRS : …………………………………….
Diagnosa Medis : …………………………………….
No Register : …………………………………….
A. DATA UMUM KLIEN
Nama Klien : Nama Suami :
Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Agama : Agama :
Penghasilan : Penghasilan :
Gol. Darah : Gol. Darah :
Alamat : Alamat :

B. RIWAYAT KESEHATAN
1. Keluhan Utama : .........................................................................
2. Riwayat Penyakit Sekarang
: .........................................................................................................
......................................................................................................................
......................................................................................................................
.....
3. Riwayat Penyakit Dahulu
: .........................................................................................................
......................................................................................................................
......................................................................................................................
..........

1
4. Riwayat Kesehatan Keluarga :
..........................................................................................................
......................................................................................................................
..............
5. Riwayat Psikososial :
..........................................................................................................
......................................................................................................................
..............
6. Pola–Pola Fungsi Kesehatan
a. Pola persepsi & tata laksana hidup sehat
..........................................................................................................
.................................................................................................................
.......
b. Pola nutrisi & metabolisme
.................................................................................................................
.................................................................................................................
...............................................................................................................
c. Pola aktivitas & latihan
.................................................................................................................
.................................................................................................................
.................................................................................................................
d. Adaptasi psikologis
1) Penerimaan terhadap kehamilan : ………………….
Masalah khusus : ……………………………………………
e. Pola hidup yang meningkatkan resiko kehamilan
..........................................................................................................
.................................................................................................................
.............................................................................
………………………………………..
f. Persiapan persalinan

2
 1) Senam hamil: ya/tidak
2) Rencana tempat melahirkan: .........................................................
3) Perlengkapan kebutuhan bayi dan ibu: tersedia/tidak
4) Kesiapan mental ibu dan keluarga:
..............................................................................................
...........................................................................................................
....
5) Pengetahuan tentang tanda-tanda melahirkan, cara menangani
nyeri, proses persalinan
...........................................................................................................
...........................................................................................................
....................................................................................................
g. Pola eliminasi
BAB : .................X/hari, Konsistensi : ....................... warna: ..............
BAK: : .................X/hari, Jumlah : ............................ Warna: ..................
h. Pola persepsi sensori
1) Penglihatan :
2) Pendengaran :
3) Penciuman :
4) Perabaan :
5) Perasaan :

C. RIWAYAT KEHAMILAN DAN PERSALINAN YANG LALU

Status obstetric : G…..P…….A………
JENIS JENIS KEADAAN BAYI MASALAH
NO TAHUN PENOLONG
PERSALINAN KELAMIN WAKTU LAHIR KEHAMILAN
1
2
3
4
5

3
Pengalaman menyusui : ya/ tidak Berapa lama : …………………………………….
Masalah saat menyusui : ada/ tidak, kalau ada jelaskan…………………………………
Riwayat ginekologi :
1. Menarche :
2. Lamanya :
3. Siklus :
4. Hari pertama haid terakhir :
5. Dismenorhoe :
6. Fluor albus :
Riwayat KB : (jenis, lama pemakaian, efek samping)
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
...
Riwayat kehamilan saat ini
HPHT : ………………………………………………
Taksiran partus : ………………………………………………
BB sebelum hamil : ………………………………………………
TD sebelum hamil : ………………………………………………
Berapa kali periksa hamil : …………………………………………

D. DATA UMUM KESEHATAN SAAT INI

1. Usia kehamilan : ……………………………
2. Pemeriksaan fisik (inspeksi, palpasi, auskultasi, perkusi)
a. Keadaan Umum:
.................................................................................................................
.................................................................................................................
..............................................................................................................
b. Tanda- tanda vital
Suhu Tubuh :

4
 Denyut Nadi :
Tekanan Darah :
Respirasi :
BB / TB :
c. Kepala & leher
Inspeksi
1) Kepala :
2) Muka :
3) Mata :
4) Hidung :
5) Mulut :
6) Telinga :
7) Leher :
Palpasi
1) Kepala :
2) Leher :
d. Thorax/ dada
Inspeksi

Auskultasi
 Pernafasan :
 Sirkulasi jantung :
e. Pemeriksaan payudara
Inspeksi
Palpasi
f. Abdomen
 Inspeksi :

 Palpasi
1) Leopold I :

5
 2) Leopold II :

3) Leopold III :

4) Leopold IV :

 Auskultasi
- DDJ :
- Frekwensi :
- Irama :
- Intensitas :
g. Genetalia dan anus
.................................................................................................................
.................................................................................................................
1) Keputihan :
2) Hemorrhoid: derajat: ………………… lokasi: ………………….Berapa lama
……………………………. Nyeri : ya/ tidak
h. Ekstremitas
Inspeksi
 Ekstremitas atas

 Ekstremitas bawah

Perkusi
Ekstremitas :

i. Integumen

6
 ……………………………………………………………………………………………………………
………………………………………………………………………….

j. Pemeriksaan Laboratorium
- Urine :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………..
- Darah :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………..
- Feses :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………….............................................
.............................................................................................
k. Pemeriksaan Diagnostik Lain
.................................................................................................................
.................................................................................................................
.................................................................................................................

7
 PENGKAJIAN INTRANATAL
Nama mahasiswa : …………………………………….
NIM : …………………………………….
Tanggal pengkajian : …………………………………….
Ruangan/ RS/ PKM : …………………………………….
Tgl, Jam MRS : …………………………………….
Diagnosa Medis : …………………………………….
No Register : …………………………………….

A. DATA UMUM PASIEN

Nama Pasien : Nama Suami :
Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Agama : Agama :
Penghasilan : Penghasilan :
Gol. Darah : Gol. Darah :
Alamat : Alamat :

B. RIWAYAT KESEHATAN
1. Keluhan Utama
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...

2. Riwayat Penyakit Sekarang

8
 ……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
3. Riwayat penyakit dahulu
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
4. Riwayat Kesehatan Keluarga
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
5. Riwayat Psikososial
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
6. Pola-pola fungsi kesehatan
a. Pola persepsi & tata laksana hidup sehat
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
b. Pola nutrisi & metabolisme
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………….
c. Pola aktivitas
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………...

d. Pola eliminasi

9
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………….....

e. Pola persepsi sensoris

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………………...

f. Pola konsep diri

 Identitas diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Peran diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Gambaran diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Harga diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Ideal diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...

10
 g. Pola hubungan & peran
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………...
h. Pola reproduksi & seksual
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………….............

i. Pola penanggulangan stres/ koping- toleransi stres

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………...
C. DATA UMUM OBSTETRI
1. Kehamilan sekarang direncanakan : ya/ tidak
2. Status obstetric : G…..P…..A……usia kehamilan……………minggu
3. HPHT…………………taksiran partus………………………….
4. Jumlah anak hidup : …………………………………………

N JENIS CARA BB TEMPAT USIA

KEADAA UMU PENOLON
O KELAMI LAHI LAHI PERSALINA KEHAMILA
N R G
N R R N N
1
2
3
4
5
5. Mengikuti kelas prenatal : ya/ tidak
6. Jumlah kunjungan ANC pada kehamilan ini : …………………………………….

11
 7. Masalah kehamilan yang lalu : ………………………………………………………….
8. Masalah kehamilan sekarang : ………………………………………………………….
9. Rencana KB : ya/ tidak, jenis apa, alasan tidak memakai apa
………………………..............................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
...............................................................................................................
10. Makanan bayi sebelumnya : ASI/ PASI/ lainnya……………………………………….
11. Pendidikan kesehatan yang diinginkan saat ini :………………………………………
Lingkari : relaksasi/ pernafasan/ manfaat ASI/ cara member minum
dengan botol/ senam nifas/ metoda KB/ perawatan perineum, lain2 :
sebutkan .......................................................................................................
................
12. Setelah bayi lahir, siapa yang diharapkan membantu : suami/ teman/
orang tua
13. Masalah dalam persalinan yang lalu : ……………………………………………………..

D. RIWAYAT PERSALINAN SEKARANG

1. Mulai persalinan (kontraksi/ pengeluaran per vaginam) tgl/ jam :
………………......................................................................................................
...................................................................................................................
2. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya,
kekuatan) : ....................................................................................................
......................................................................................................................
.................
3. Frekuensi, kualitas, dan keteraturan denyut jantung janin :
………………………..............................................................................................
......................................................................................................................
...............................................................................................................

12
4. Pemeriksaan fisik (inspeksi, palpasi, auskultasi, perkusi)
a. Keadaan Umum:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………..
b. Tanda- tanda vital
Suhu Tubuh :
Denyut Nadi :
Tekanan darah :
Respirasi :
BB / TB :
Kenaikan BB selama kehamilan :
c. Kepala & leher
Inspeksi
1) Kepala :
2) Muka :
3) Mata :
4) Hidung :
5) Mulut :
6) Telinga :
7) Leher :
Palpasi
 Kepala :

 Leher :
8) Thorax/ dada
Inspeksi

13
Auskultasi
 Pernafasan :

 Sirkulasi jantung :

9) Pemeriksaan payudara
Inspeksi

Palpasi

10) Abdomen
 Inspeksi :

 Palpasi
1) Leopold I :

2) Leopold II :

3) Leopold III :

4) Leopold IV :

 HIS
- Frekwensi :
- Durasi :
- Intensitas :
 Auskultasi
- DDJ :
- Frekwensi :

14
 - Irama :
- Intensitas :

11) Genetalia dan anus

……………………………………………………………………………………………………………
………………………………………………………………………….
- Keluaran pervaginam :
- Vagina Toucher: (jam …………….. oleh: …………………………………
Hasil ………………………………………………………………………………...
- Ketuban ……………………………………………………………………………..
- Anus …………………………………………………………………………………
- Kesimpulan ………………………………………………………………………….
12) Punggung
Inspeksi

13) Ekstremitas
Inspeksi
 Ekstremitas atas

 Ekstremitas bawah

Perkusi
Ekstremitas :

14) Integumen

15
 ……………………………………………………………………………………………………………
………………………………………………………………………….

15) Pemeriksaan Laboratorium

- Urine :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………..
- Darah :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………..
- Feses :
………………………………………………………………………………………………………
………………………………………………………………………………………………………
……………………………………………………………..
16) Pemeriksaan Diagnostik Lain
……………………………………………………………………………………………………………
…………………………………………………………………………..

E. DATA PSIKOSOSIAL
1. Penghasilan keluarga setiap bulan : Rp ........................................
2. Perasaan klien terhadap kehamilan sekarang
......................................................................................................................
......................................................................................................................
......................................................................................................................
...
3. Perasaan suami terhadap kehamilan sekarang

16
 ......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
....

4. Respon sibling terhadap kehamilan sekarang

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

17
 LAPORAN PERSALINAN

I. Kala I / Pembukaan ostium uteri (pemeriksaan toucher dan

sebagainya)
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.
II. Kala II / Pengeluaran Bayi:
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
III. Kala III / Pengeluaran Uri:
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

18
IV. Kala IV / mulai pengeluaran uri sampai 2 jam post partum (kontraksi
uteri, TFU, pengeluaran darah pervaginam, observasi tanda-tanda
vital/ keadaan umum ibu)
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
CATATAN LUAR BIASA:
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

19
 LAPORAN PERSALINAN
1) Keluhan His
teratur tidak
Interval :
Lama :

2) Pengeluaran Pervagina
Jenis : lendir Darah Darah Lendir Air ketuban
3) Periksa Dalam : Jam :
Oleh :
Hasil :
4) Kala persalinan
a. Kala I
- Mulai persalinan :
- Lama kala I :
- Perdarahan :
- Pengobatan yang didapat :
- Keluhan :

b. Kala II
- Mulai persalinan :
- Lama kala II :
- Keadaan umum :
- VT :
- Perineum :
- Vulva dan anus :
- Perdarahan :
- Pengobatan yang didapat :
- Penyulit :
- Cara mengatasi :

20
 - Keadaan bayi :
Lahir Tgl :
Jenis kelamin :
Apgar score 1 :
Apgar score 5 :
- Keluhan :

c. Kala III
- Mulai persalinan :
- TFU setinggi pusat kontraksi uterus : baik jelek
- Lama kala III :
- Cara kelahiram plasenta : Spontan tindakan
Sebutkan:
- Kotiledon : Lengkap Tidak
- Selaput : Lengkap Tidak
- Perdarahan selama persalinan :
- Pengobatan yang didapat :
- Keluhan :

d. Kala IV:
- Keadaan umum :
- Tanda vital :
TD : RR :
N : S :
- TFU :
- Kontraksi uterus : baik jelek
- Perdarahan : ya tidak
- Perdarahan : cc
- Perineum : Ruptur spontan Episiotomi
- Pengobatan :

21
 - Keluhan :
5) Keadaan Bayi:
a. BB :
b. PB :
c. Pusat : Normal Abnormal
d. Perawatan tali pusat :
Alkohol 70 %
Bethadin
Lainnya :………………….
e. Anus : Berlubang Tertutup
f. Suhu :
g. Lingkar Kepala :
Lingkaran Sub Occipito Bregnatica :
Lingkaran fronto Occipitalis :
Lingkaran Mento Occipitalis :
h. Kelainan Kepala :
Caput Succedanum Cephal hematoma
Hidrocephalus Microcephalus
An encephalus
Keterangan:
1.. Lampirkan Partograf

22
 PENGKAJIAN POSTPARTUM
Nama mahasiswa : …………………………………….
NIM : …………………………………….
Tanggal pengkajian : …………………………………….
Ruangan/ RS/ PKM : …………………………………….
Tgl/Jam MRS : …………………………………….
Diagnosa Medis : …………………………………….
No Register : …………………………………….

A. DATA UMUM PASIEN

Nama Pasien : Nama Suami :
Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Agama : Agama :
Penghasilan : Penghasilan :
Gol. Darah : Gol. Darah :
Alamat : Alamat :

B. RIWAYAT KESEHATAN
1. Keluhan Utama
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...

2. Riwayat Penyakit Sekarang

……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
3. Riwayat penyakit dahulu

23
 ……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
4. Riwayat Kesehatan Keluarga
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
5. Riwayat Psikososial
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
…………………………………………………………...
6. Pola-pola fungsi kesehatan
a. Pola persepsi & tata laksana hidup sehat
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
b. Pola nutrisi & metabolisme
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………….
c. Pola aktivitas
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………...

7. Pola eliminasi
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………….......................................................
8. Pola persepsi sensoris

24
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………………...

9. Pola konsep diri

 Identitas diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Peran diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Gambaran diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Harga diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...
 Ideal diri:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………...

10. Pola hubungan & peran

25
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………...
11. Pola reproduksi & seksual
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………….............

12. Pola penanggulangan stres/ koping- toleransi stres

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………...

C. Riwayat Pengkajian Obstetri, Prenatal Dan Intranatal

1. Riwayat Kehamilan dan
Persalinan yang Lalu
KEADAAN
TIPE JENIS BB MASALAH
NO TAHUN PENOLONG BAYI WAKTU
PERSALINAN KELAMIN LAHIR KEHAMILAN
LAHIR

2. Riwayat penggunaan kontrasepsi

……………………………………………………………………………………………………………
…………………………………………………………………………………..
………………………………………………………………………………….............................
...........................

3. Riwayat menstruasi

26
  Menarche : ………………………………………………………………
 Lamanya : ………………………………………………………………
 Siklus : ………………………………………………………………
 Haid pertama haid terakhir : …………………………………………………………
 Dismenorhoe : ………………………………………………………………
 Fluor albus : ………………………………………………………………
4. Riwayat kehamilan sekarang
……………………………………………………………………………………………………………
………………………………………………………………………….

Riwayat Kehamilan Saat Ini (berupa narasi)

1. Berapa kali periksa hamil:
2. Masalah kehamilan

Riwayat Persalinan
1. Jenis persalinan: Spontan (letkep/letsu) / SC a/I ...................
Tgl/Jam: .........................
2. Jenis kelamin bayi: L/P, BB/PB ....... gram/ ......... cm, A/S: .....................
3. Perdarahan ........... cc
4. Masalah dalam persalinan ...........................................................................
Riwayat Ginekologi
1. Masalah Ginekologi
2. Riwayat KB (jenis, lama pemakaian, efek samping)

DATA UMUM KESEHATAN SAAT INI

27
Status Obstretik: P ....... A ........ Bayi Rawat Gabung: ya/tidak
1. Jika tidak alasan:.....................................................................................
2. Pemeriksaan fisik (inspeksi, palpasi, auskultasi, perkusi)
a. Keadaan Umum:
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………..
b. Tanda- tanda vital
 Tekanan Darah :
 Nadi :
 Respirasi :
 Suhu :
 BB :
 Tinggi badan :

c. Kepala & leher

Inspeksi
1) Kepala :
2) Muka :
3) Mata :
4) Hidung :
5) Mulut :
6) Telinga :
7) Leher :
Palpasi
 Kepala :

 Leher :
d. Thorax/ dada
Inspeksi

28
 Auskultasi
 Pernafasan :

 Sirkulasi jantung :

e. Pemeriksaan payudara
Inspeksi

Palpasi

f. Abdomen
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………......................................................
- TFU…………………………………………………………………………………
- Kontraksi ………………………………………………………………………….
- Diastasis Rectus Abdominus………………………………………………………..
g. Genetalia dan anus
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………..
 Episiotomi (tanda REEDA)
………………………………………………………………………………………………………
…………………………………………………………………………..
 Lochea………………………………………………………………………………..
 Anus …………………………………………………………………………………
i. Punggung
Inspeksi

j. Ekstremitas

29
 ……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………………..
- Human Sign…………………………………………………………………………
- Varises ……………………………………………………………………………..
k. Integumen

I. Pemeriksaan laboratorium
- Urine
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………..
- Darah
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………..
- Feses
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………..
II. Pemeriksaan diagnostik lain
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………..

BAB saat ini........................ konstipasi: ya/tidak

Masalah khusus: ..................................................................................................
Istirahat dan Kenyamanan: ..................................................................................
KEADAAN BAYI SAAT LAHIR

30
Lahir tanggal: ............................... Jam: .............. Jenis Kelamin ..................
Kelahiran: tunggal/gemelli*)

NILAI APGAR
TANDA NILAI JUMLAH
0 1 2
Denyut □○ Tidak ada □○ < 100 □○ > 100
Jantung
Usaha Nafas □○Tidak ada □○ Lambat □○Menangis
Tonus Otot □○Lumpuh □○Ekstremitas Kuat
fleksi sedikit □○Gerakan aktif
Iritabilitas/ □○Tidak □○Gerakan
Reflek bereaksi sedikit □○Reaksi
melawan
Warna □○Biru/pucat □○Tubuh □○Kemerahan
kemerahan,
tangan dan kaki
biru
Keterangan: □ penilaian menit ke-1, ○ penilaian menit ke-5
Tindakan resusitasi...........................................................................................
Plasenta: Berat ....................... Talipusat: Panjang ......................................
Ukuran .......................... Jumlah pembuluh darah ....................................
Kelainan..............................................................................................
Hasil pemeriksaan penunjang .............................................................................

Pengkajian Fisik
o Umur ....... hari ......... jam

31
Berat Badan ................................. gr Mulut Simetris
Panjang Badan ................................. cm  Palatum mole
Suhu .................................o C  Palatum curum
Lingkar Kepala ................................. cm  Gigi
Lingkar Dada ................................. cm Hidung  Lubang hidung
Lingkar Perut ................................. cm Keluaran
 Pernafasan cuping radung
KEPALA
Bentuk  Bulat TUBUH
Kepala  Lain-lain Warna  Pink
 Molding  Pucat
 Kaput  Sianosis
 Cephalhematom  Kuning
Pergerakan  Aktif
Ubun-ubun Besar Kurang
Kecil
Sutura Dada Simetris
Mata Posisi .......................... Asimetris
Kotoran Retraksi
Perdarahan Seesaw
Telinga Posisi .......................
Bentuk.......................... STATUS NEUROLOGI
Lubang telinga Refleks Tendon
Keluaran (dinilai semua) Moro
Jantung & paru- normal Rooting
paru Menghisap
Bunyi nafas ngorok Babinski
lain-lain Menggenggam
Bunyi nafas ............................ x/menit Menangis
Denyut jantung ........................ x/menit Berjalan
Tonus leher
Perut lembek NUTRISI
kembung Jenis makanan ASI
benjolan PASI
Bising usus .......... x/menit Lain-lain
Lanugo ....................................................

32
 Vernix ......................................................
PUNGGUNG ELIMINASI
Keadaan punggung simetris BAB Pertama: tgl .................... jam ........
Asimetris BAK Pertama: tgl ................... jam .........
Pilonidal dimple
Fleksibilitas tulang kelainan........
punggung
DATA LAIN YANG MENUNJANG
GENETALIA (Lab, psikosal, dll)
Laki-laki Normal
Hypospadius
Epispadius
Testis ................................
Perempuan
Labia minora Menonjol
Tertutup labia mayor
Keluaran ...........................
Anus Kelainan ........................
EKSTREMITAS
Jari tangan Kelainan .......................
Jari kaki Kelainan ....................... Kesimpulan
Pergerakan Tidak aktif
Asimetris
Tremor
Rotasi paha
Nadi Brachial ..........................
Femoral .........................
Posisi Kaki ..................................
Tangan ............................

KET: *Bayi baru lahir yang dikaji berusia ≤ 24 jam

ANALISA DATA
NO PENGELOMPOKAN DATA PENYEBAB Masalah

33
 DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN PRIORITAS
NO DIAGNOSA KEPERAWATAN

34
35
 INTERVENSI KEPERAWATAN
PERENCANAAN RASIONAL PARAF
NO DIAGNOSA KEPERAWATAN
NOC NIC

36
 IMPLEMENTASI
DIAGNOSA KEPERAWATAN TGL/JAM TINDAKAN PARAF

37
 EVALUASI
DIAGNOSA KEPERAWATAN TGL/JAM CATATAN PERKEMBANGAN PARAF

38
 RESUME ASUHAN KEPERAWATAN MATERNITAS
Nama Pasien : Tgl MRS :
Dx. Medis : No. RM :
Umur Pasien :
Pengkajian Fokus Rumusan Diagnosa Intervensi
NOC NIC Implementasi Evaluasi
(DO dan DS) Keperawatan

39
 RESUME ASUHAN KEPERAWATAN MATERNITAS
Nama Pasien : Tgl MRS :
Dx. Medis : No. RM :
Umur Pasien :
Pengkajian Fokus Rumusan Diagnosa Intervensi
NOC NIC Implementasi Evaluasi
(DO dan DS) Keperawatan

40
 GANGGUAN REPRODUKSI

Nama mahasiswa : …………………………………….

NIM : …………………………………….
Tanggal pengkajian : …………………………………….
Ruangan/ RS/ PKM : …………………………………….
Tgl/Jam MRS : …………………………………….
Diagnosa Medis : …………………………………….
No Register : …………………………………….

I. BIODATA
Nama Klien : ……………………… Nama Klien : ……………………………..
Umur : ……………………… Umur : ……………………………..
Suku/ Bangsa : …………………….. Suku/ Bangsa : ……………………………...
Pendidikan : ……………………… Pendidikan : …………………………….
Pekerjaan : …………………….. Pekerjaan : …………………………….
Agama : …………………….. Agama : ……………………………..
Penghasilan : …………………….. Penghasilan : ……………………………..
Gol. Darah : …………………….. Gol. Darah : ……………………………..
Alamat : …………………….. Alamat : …………………………….
Kehamilan : ……………………..

II. RIWAYAT KESEHATAN

1. Keluhan Utama
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
........................................................................................................................................
2. Riwayat Penyakit Sekarang
....................................................................................................................................................
....................................................................................................................................................

41
 ....................................................................................................................................................
........................................................................................................................................

3. Riwayat penyakit dahulu

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
........................................................................................................................................
4. Riwayat Kesehatan Keluarga
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
........................................................................................................................................
5. Riwayat Psikososial
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
........................................................................................................................................
6. Pola-pola fungsi kesehatan
a. Pola persepsi & tata laksana hidup sehat
..............................................................................................................................................
..............................................................................................................................................
......................................................................................................................................
b. Pola nutrisi & metabolisme
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
c. Pola aktivitas
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................

42
d. Pola eliminasi
..............................................................................................................................................
..............................................................................................................................................
......................................................................................................................................
e. Pola persepsi sensoris
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
f. Pola konsep diri
 Identitas diri:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
...
 Peran diri:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
...
 Gambaran diri:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
...
 Harga diri:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
...
 Ideal diri:
.........................................................................................................................................
.........................................................................................................................................

43
 .........................................................................................................................................
...

g. Pola hubungan & peran

..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
h. Pola reproduksi & seksual
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
i. Pola penanggulangan stres/ koping- toleransi stres
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………........

7. Riwayat pengkajian obstetri, prenatal dan intranatal

a. Riwayat menstruasi
 Menarche : ………………………………………………………………
 Lamanya : ………………………………………………………………
 Siklus : ………………………………………………………………
 Haid pertama haid terakhir : ………………………………………………………………
 Dismenorhoe : ………………………………………………………………
 Fluor albus : ………………………………………………………………
 Menopause : ………………………………………………………………
b. Riwayat perkawinan
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
c. Riwayat kehamilan dan persalinan

44
 ..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

d. Riwayat keluhan obstetric

..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
e. Riwayat penggunaan kontrasepsi
..............................................................................................................................................
..............................................................................................................................................
.....................................................................................................................................
8. Riwayat Ginekologi
....................................................................................................................................................
....................................................................................................................................................
.........................................................................................................................
9. Pemeriksaan fisik (inspeksi, palpasi, auskultasi, perkusi)
a. Keadaan Umum:
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
b. Tanda- tanda vital
 Tekanan Darah :
 Nadi :
 Respirasi :
 Suhu :
 BB :
 Tinggi badan :

c. Kepala & leher

Inspeksi

45
 1) Kepala :
2) Muka :
3) Mata :
4) Hidung :
5) Mulut :
6) Telinga :
7) Leher :
Palpasi
 Kepala :

 Leher :
d. Thorax/ dada
Paru
1) Inspeksi
2) Palpasi
3) Perkusi
4) Auskultasi
Jantung
1) Inspeksi
2) Palpasi
3) Perkusi
4) Auskultasi

e. Pemeriksaan payudara
Inspeksi

Palpasi

f. Abdomen
1) Inspeksi

2) Auskultasi

46
 3) Palpasi

4) Perkusi

g. Genetalia dan anus

…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
h. Punggung
Inspeksi

Palpasi

i. Ekstremitas
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
j. Integumen

III. Pemeriksaan laboratorium

Urine
...................................................................................................................................................
...................................................................................................................................................
Darah
...................................................................................................................................................
...................................................................................................................................................
Feses
...................................................................................................................................................
...................................................................................................................................................
IV. Pemeriksaan diagnostik lain

47
...................................................................................................................................................
...................................................................................................................................................
..................................................................................................................................................
.......................................,2019
Pemeriksa

48
49