PENGKAJIAN ANTENATAL CARE

Nama Mahasiswa : Tanggal Pengkajian :

NIM : RS/Ruangan :

I. DATA UMUM
Inisial Pasien : Nama Suami :
Umur : Umur :
Pekerjaan : Pekerjaan :
Pendidikan Terakhir : Pendidikan Terakhir :
Agama : Agama :
Suku Bangsa :
Status perkawinan :
Alamat :

II. DATA UMUM KESEHATAN

a. Keluhan Utama :

b. Tujuan Kunjungan ANC :

c. Riwayat keluhan Utama :

d. Riwayat kesehatan Saat Ini :

e. Riwayat kesehatan keluarga (Genogram ):

III. PERSEPSI DAN HARAPAN KLIEN SEHUBUNGAN DENGAN KEHAMILAN

Stase Keperawatan Maternitas Program Profesi NERS FIKES
UMGo
 a. Alasan klien ke klinik :
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b. Perubahan fisik maupun psikologis selama kehamilan
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c. Dukungan Keluarga
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d. Rencana melahirkan
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e. Rencana ASI Ekslusif/PASI
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f. Riwayat dan Rencana KB
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g. Pelajaran yang diinginkan saat ini :

relaksasi/pernafasan/manfaat ASI/cara memberi minun/senam nifas/metoda KB/perawatan
perineum/perawatan payudara
lain-lain ..........................................................................................................................
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h. Harapan klien
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III. DATA UMUM OBSTETRI

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 a. Kehamilan sekarang direncanakan (ya/tidak) jelaskan :
...........................................................................................................................................
b. Status Obstetric :
G P A H...........................................................................................................
c. HPHT :
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d. Usia Kehamilan :
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e. Taksiran partus :
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f. Taksiran Berat janin :
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g. Mengikuti kelas prenatal (senam hamil )
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h. Jumlah kunjungan ANC
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i. TFU :
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j. Riwayat Imunisasi TT
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i. Pemberian Tablet Zat Besi :
j. Riwayat Persalinan
Kehamilan Jenis Gangguang Cara Masalah Penolong Masalah Masalah Keadaan
Ke- Kelamin Kehamilan Persalinan Persalinan Persalinan Nifas Bayi Anak
1
2

IV. KEBUTUHAN DASAR KHUSUS

a. Kenyamanan Istirahat Tidur
1. Ketidaknyamanan
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2. Istirahat dan Tidur
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3. Hygiene Prenatal
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b. Keselamatan
1) Pergerakan
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2) Penglihatan
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Stase Keperawatan Maternitas Program Profesi NERS FIKES
UMGo
 ...................................................................................................................................
3) Pendengaran
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4) Cairan
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c. Nutrisi
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d. Gaya Hidup
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e. Eliminasi
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f. Oksigenasi
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g. Seksualitas
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V. PEMERIKSAAN FISIK (HEAD TO TOE)
a. Antropometri
TB :
BB Sebelum Hamil :
BB Saat Ini :
Lingkar Lengan :
b. Tanda Vital : TD : , Nadi : , Respirasi : Suhu :
c. Keadaan Umum:
d. Kepala :
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e. Mata :
........................................................................................................................................................
........................................................................................................................................................
f. Hidung :
g. Telinga :

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
h. Leher :
i. Jantung
Inspeksi
:..........................................................................................................................
Palpasi :...............................................................................................................
...........
Perkusi
:..........................................................................................................................
Auskultasi :...............................................................................................................
...........
j. Paru-paru
Inspeksi
:..........................................................................................................................
Palpasi :...............................................................................................................
...........
Perkusi
:..........................................................................................................................
Auskultasi
:..........................................................................................................................
k. Payudara

Inspeksi
:..........................................................................................................................
Palpasi :...............................................................................................................
...........
l. Abdomen
Inspeksi :..................................................................................................
........................
Auskultasi :...............................................................................................................
...........
Palpasi
Leopold I
:..........................................................................................................................
Leopold II
:..........................................................................................................................

Leopold III
:..........................................................................................................................

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 Leopold IV
:..........................................................................................................................

Perkusi :...............................................................................................................
...........
m. Perianal :...............................................................................................................
...........
n. Anus :...............................................................................................................
...........
o. Ekstremitas :...............................................................................................................
...........
p. Kulit, Kuku
:..........................................................................................................................
q. Refleks Patella
:..........................................................................................................................

VI. PEMERIKSAAN PENUNJANG

Tanggal :
USG :
Laboratorium :
Dll

VII. PENGKAJIAN PSIKOSOSIAL

a. Penerimaan ibu terhadap kehamilannya
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b. Dukungan keluarga terhadap kehamilan
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c. Upaya dalam meningkatkan ikatan antara ibu, ayah, saling dengan bayi
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d. Upaya keluarga dalam menyiapkan kebutuhan terhadap kehamilan

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Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 e. Persiapan menjadi orang tua
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f. Perasaan akan menjadi ibu
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PENGKAJIAN KLINIK KELUARGA BERENCANA

Nama Mahasiswa :

Tanggal :

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
1. Initial Klien :......................................................................................................
2. Status Perkawinan :......................................................................................................
3. Jumlah Anak :......................................................................................................
4. Alasan Datang ke PKM/RS:
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5. Penggunaan KB Saat Ini :
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6. Alasan Menggunakan KB :
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7. Apakah ada masalah dalam penggunaan KB Saat ini :
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8. Riwayat Penggunaan KB

Pengguanaan
NO Tgl Lahir/Umur Tipe Persalinan Keadaan Sekarang
KB Setelah Persalinan

9. Riwayat Kesehatan
a. Apakah Ibu Merokok :
b. Apakah Ibu Minum Alkohol :
10. Riwayat Penyakit :

11. Menstruasi Terakhir :

12. Lama Perkawinan :

13. Rangkuman Masalah :

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 14. Diagnosa Keperawatan :

15. Rencana Tindakan :

16. Implementasi :

PENGKAJIAN INTRANATAL CARE

Nama Preseptee : Tanggal Pengkajian :

NIM : RS/Ruangan :

A. IDENTITAS KLIEN
Nama :
Umur :
Alamat :
Agama :
Stase Keperawatan Maternitas Program Profesi NERS FIKES
UMGo
 Suku Bangsa :
Staus Perkawinan :
Pekerjaan :
Status Obstetri :

B. ALASAN MASUK RS
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C. KELUHAN UTAMA
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D. PENGKAJIAN AWAL
Tanggal : ……………………………………. Jam: ………………………………….
Tanda vital :Tekanan Darah ……... ..mmHg
Frekuensi Nadi ……… x/menit
Frekuensi Pernapasan ........x/menit
Suhu ……… 0C
Pemeriksaan palpasi abdomen :
Leopold I :......................................................................................................................................................
Leopold II :......................................................................................................................................................
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Leopold III :......................................................................................................................................................
Leopold IV :.....................................................................................................................................................
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Hasil periksa dalam :
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Dilakukan klisma, (ya/tidak),jika ya, jelaskan : ..
………………………………………………..................................................................................................
Pengeluaran pervaginam ...…………...................................................
…………………………………………………..........................
Perdarahan pervaginam (ya/tidak), jelaskan ..…………………………………………...................................
Kontraksi uterus (frekuensi, lamanya, kekuatan) .…………………………………….....................................
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Denyut jantung janin (frekuensi, kualitas)...………………………………………….....................................
Status janin (hidup/tidak, jumlah, presentasi)……………………………………….......................................
E. KEADAAN UMUM:
1. Kepala : .......................................................................................................................................
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Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 2. Mata : .......................................................................................................................................
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3. Hidung : .......................................................................................................................................
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4. Telinga : .......................................................................................................................................
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5. leher : .......................................................................................................................................
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6. Jantung : .......................................................................................................................................
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7. Paru-paru : .......................................................................................................................................
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8. Payudara : .......................................................................................................................................
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9. Abdomen (secara umum dan pemeriksaan obstetrik)
Leopold I :......................................................................................................................................................
Leopold II :......................................................................................................................................................
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Leopold III :......................................................................................................................................................
Leopold IV :.....................................................................................................................................................
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10. Perianal : .......................................................................................................................................
11. Anus : .......................................................................................................................................
12. Ekstremitas : .......................................................................................................................................
13. Kulit, Kuku : .......................................................................................................................................
14. Refleks Patella : .......................................................................................................................................

F. PERSALINAN KALA I
Mulai persalinan : tanggal ………………………… jam ……………………………..
Tanda dan gejala ..……………………………………………………………………..
Tanda vital : Tekanan Darah ……... mmHg,
Frekuensi Nadi ……… x/menit
Frekuensi pernapasan
Suhu ……… 0C
Tindakan.............................................................................................................................................................
Observasi kemajuan persalinan
Tanggal/jam Kontraksi uterus DJJ Ket

Stase Keperawatan Maternitas Program Profesi NERS FIKES

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 Pengobatan…………………………………………………......................................................................
Lama kala I ………………. Jam …………………… Menit …………….............. Detik
Keadaan psikososial ……………………………………………………………………
G. PERSALINAN KALA II
Kala II dimulai: tanggal ……………………… Jam ……………………………………
Tanda- Tanda vital :
TD ……... mmHg, Nadi ……… x/menit, Suhu …….....º C, P …….... X/menit
Tanda dan gejala ………………………………………………………………………
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Tindakan……………………………………………………………………………….
Jelaskan upaya meneran………………………………………………………………..
... .......................................................................................................................................
Keadaan psikososial..…………………………………………………………………..
Kebutuhan khusus.……………………………………………………………………..
Lama kala II …………………… jam ……………….. Menit …………………. Detik
Jenis Kelamin : .................................................................................................................
H. KALA III
Tanda dan gejala:……………………………………………………………………...
.. .......................................................................................................................................
Tindakan……………………………………………………………………………….
.. .......................................................................................................................................
Plasenta lahir jam: .……………………………………………………………………
Cara lahir plasenta:………………………………………………………………….....
.. .......................................................................................................................................
Karakteristik Plasenta:
Ukuran …………….. cm x ………………… cm x …………………cm
Panjang tali pusat ……………………………………………….……cm
Jumlah Kotiledon dan Selaput...............................................................................................................
Perdarahan …………………………. ml
Karakteristik …………………………………………………………………….…….....................
Keadaan Psikososial l : …………………………………………………………………………….
Pengobatan …………………………………………………………………………......................

I. KALA IV
Mulai jam ……………………………………………………………………………

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
Tanda vital : Tekanan Darah ……... mmHg
Frekuensi Nadi …….. x/menit
Frekuensi Pernapasan .............x/menit
Suhu …… 0C
Tindakan……………………………………………………………………………
Kontraksi uterus :……………………………………………………………………...
Perdarahan ……………………… ml, Karakteristik ………………………………..
Bonding bayi dan ibu………………………………………………………….….......

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 LEMBAR OBSERVASI PARTOGRAF

Stase Keperawatan Maternitas Program Profesi NERS FIKES

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 PENGKAJIAN BAYI BARU LAHIR

A. IDENTITAS
Inisial Nama Ibu Bayi :..........................................................................................................................
Tanggal / jam pengkajian : .........................................................................................................................
Nama Ayah : .........................................................................................................................
Pekerjaan : .........................................................................................................................
Alamat :.........................................................................................................................
B. KEADAAN BAYI BARU LAHIR
Lahir tanggal : ….…. Jam : ….….
Sex : ….….
Kelahiran : ….….
Berat badan Lahir : ….….
Panjang : ….….cm
HR : ........ x/menit
Pernapasan : .......... x/menit
Suhu : : ........... 0c
C. NILAI APGAR
N
TANDA 0 1 2 JUMLAH
O

1. Frekwensi Tidak ada < 100 > 100

jantung
Tidak ada Lambat Menangis kuat
2. Usaha nafas
Lumpuh Ektrimitasfleksisedikit Gerakan aktif
3. Tonus otot
Tidak beraksi Gerakan sedikit Reaksi malawan
4. Refleks
Biru pucat Tubuh kemerahan, Kemerahan
5. Warna kulit tangan dan kaki biru.

Ket : penilaian menit ke 1 = ....... penilaian menit ke 5 = ........

Tindakan resusitasi :.............................................................................................................
Tali pusat : ............................................................................................................

D. PENGKAJIAN FISIK
Umur :...........................................................................................................................
Berat badan : ............ gr
Panjang : ............... cm
Antropometri :
BBL : ................. gr BB sekarang : ................ gr
LK : .......... cm
LP : ......... cm
LD : .......... cm
PL : ........... cm
PK : ........... cm
LLA : .......... cm

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
 PB : ......... cm
Tanda – tanda vital :
Frekuensi Nadi : .......... x/menit
Pernapasan : ...........x/menit
Suhu : : .........0C

KEPALA
1) Bentuk : ........................................................................................................................................
2) Ubun – ubun :.........................................................................................................................................
3) Mata :........................................................................................................................................
4) Telinga :........................................................................................................................................
5) Mulut :........................................................................................................................................
6) Hidung :........................................................................................................................................
7) Leher :........................................................................................................................................

TUBUH
1) Warna : ………………………………………………………….............................................
2) Pergerakan : …………………………………………………………………….............................
3) Dada : ……………………………………………………………….....................................
4) Vernik kaseosa : ……………………………………………………………………............................

JANTUNG DAN PARU

1) Bunyi nafas :
2) Pernafasan : ……………….. X/ menit
3) Hate rate : ……………….. X/ menit

PERUT DAN ABDOMEN

1) Gerakan diagpragmatik : ……………………………...........................................................

PUNGGUNG
1) Keadaan punggung : ……………………………………………………………………….
2) Lanugo : ..............................................................................................................
GENITALIA
1) Anus : ………………………………………………………………………
2) Keadaan : ………………………………………………………………………

EKTRIMITAS
1) Jumlah jari tangan : ………………………………………………………………………..
2) Jari kaki : ………………………………………………………………………..
3) Pergerakan : ………………… …………………………………………………….
Stase Keperawatan Maternitas Program Profesi NERS FIKES
UMGo
4) Garis telapak kaki : ……………………………………………………………………….
5) Posisi kaki dan tangan : ……………………………………………………………………….

STATUS NEUROLOGIS
Refleks – reflleks :
1) Tendon : ……………………………………………………………………
2) Moro : ……………………………………………………………………
3) Rooting : ……………………………………………………………………
4) Mengisap : ............................................................................................................
5) Babinsky : ………………………………………………………………………
6) Menggenggam : ............................................................................................................
7) Menangis : ............................................................................................................
8) Tonus leher : ..............................................................................................................

NUTRISI
1) Jenis makanan : ..............................................................................................................
2) Diberikan dengan : ..............................................................................................................
Jumlah yang diberikan : .............................................................................................................

TERAPI :
Pemberian Imunisasi Hb 0 :
Pemberian Vitamin K :
Pemberian Salep Mata :

Rangkuman Masalah :

Perumusan Masalah :

Stase Keperawatan Maternitas Program Profesi NERS FIKES

UMGo
Rencana Tindakan :

Implementasi :

Stase Keperawatan Maternitas Program Profesi NERS FIKES

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 FORMAT PENGKAJIAN POSTNATAL

Nama Mahasiswa : Tanggal Pengkajian :

NIM : Ruangan / RS :

I. Data Umum Klien

1. Initial Pasien : Initial Suami :
2. Usia : Usia :
3. Status Perkawinan : Status perkawinan :
4. Pekerjaan : Pekerjaan :
5. Pendidikan Terakhir : Pendidikan terakhir :

Riwayat Kehamilan dan persalinan Yang Lalu

No Tahun Tipe Penolong Jenis BB Keadaan Bayi Masalah Kehamilan

Persalinan Kelamin lahir Waktu

1
2
3
4
5

Pengalaman menyusui : ya / tidak Lamanya :..............

Riwayat Kehamilan Saat Ini
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
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Beberapa Kali Periksa Hamil:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Masalah Kehamilan:
……………………………………………………………………………………………………………………
Riwayat Persalinan
1. Jenis Persalinan : Spontan ( letkep/letsu)/Tindakan ( EF/EV )…......
Sc a/I ………………. Tgl/ jam …………………..
2. Jenis Kelamin Bayi: L/P, BB/PB: ……... Gram/……....cm, A/S ……..…
Perdarahan ……………cc
Masalah dalam Persalinan ……………………………………………………….

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

 Riwayat Ginekologi :
……………………………………………………………………………………………………………………
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Masalah Ginekologi :
……………………………………………………………………………………………………………………
……………………………………………………………………………....
Riwayat KB :
……………………………………………………………………………………………………………………
………………………………………………………………………………

II. Data Umum Kesehatan Saat Ini

Status Obstetrik: G …P …A …
Bayi Rawat Gabung: ya/tidak Jika tidak alasannya …………………....……………….
Keadaan umum: …………………… Kesadaran: …………........................
BB :..........kg
TB: …….. cm

Tanda Vital
Tekanan Darah : ….......................……mmHg
Frekuensi Nadi : ……. .........................x/menit
Suhu : ……..........................ºC
Frekuensi Pernafasan : ……………….. x/menit
Kepala Leher:
Kepala :

Mata :

Hidung :

Mulut :

Telinga :

Leher :
Masalah Khusus : ……………………………………………………
Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo
 Dada:
Jantung :

Paru :

Payudara :

Puting Susu :

Penyaluran ASI:
Masalah Khusus: …………………………………………………………….....
Abdomen
Involusi Uterus
Fundus uterus: …………… Kontraksi: …………… Posisi: …………….
Kandung Kemih
Fungsi pencernaan
Masalah Khusus : ……………………………………………..
Perineum dan genital
Vagina: Integritas kulit ………edema ………. memar ………. Hematom ……..

Perineum: Utuh/Episiotomi/Ruptur Tanda REEDA:

R : Kemerahan: ya / tidak
E : Bengkak : ya / tidak
E : echimosis : ya / tidak
D : discharge : serum/pus/darah/tidak ada
A : approximate : baik / tidak
Kebersihan : ………………………………………………………………..
Lochea :
Jumlah:
Jenis warna:
Konsistensi:
Bau:
Hemorrhoid : derajat : ……………………, Lokasi ; …………………………
Berapa lama ……………………………… nyeri : ya / tidak
Masalah khusus : …………………………………………………………………

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

Ekstremitas
Ekstremitas atas : edema : ya / tidak, rasa kesemutan/baal : ya/tidak
Ekstremitas bawah : edema : ya / tidak, lokasi …………………………………
Varises : ya / tidak, lokasi …………………………………………………………
Tanda Homan : +/-
Masalah Khusus : …………………………………………………………………
Eliminasi
Urin : Kebiasaan BAK …………………………………………………….
BAK saat ini ……………………………………… nyeri : ya / tidak
BAB : Kebiasaan BAB ……………………………………………………
BAB saat ini …………………………………….. Kontipasi : ya/tidak
Masalah Khusus : …………………………………………………………..

Istirahat dan Kenyamanan

Pola tidur : kebiasaan tidur, lama …… jam, frekuensi …………………………
Pola tidur saat ini ……………………………………………………………..
Keluhan ketidaknyamanan: ya / tidak, lokasi ……………………………………….
Sifat …………………………. Insentitas ………………………………
Mobilisasi dan latihan
Tingkat mobilisasi : ………………………………………………………………
Latihan/senam : …………………………………………………………………
Masalah Khusus : ……………………………………………………………
Nutrisi dan Cairan
Asupan Nutrisi : ……………………. Nafsu makan: baik/kurang/tidak ada
Asupan cairan : …………………………………….. cukup / kurang
Masalah Khusus : ……………………………………………………………..
Keadaan Mental
Adaptasi psikologis : …………………………………………………………
Penerimaan terhadap bayi : …………………………………………………..
Taking In :
Masalah khusus : ……………………………………………………………….
Kemampuan menyusui : ………………………………………………………............
Obat-obatan:

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

Perencanaan Pulang :

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

 FORMAT PENGKAJIAN GSR

Nama Mahasiswa : NIM :

Tempat Praktek : Tanggal :

A. Identitas Klien
1. Nama :
2. Umur :
3. Alamat :
4. Agama :
5. Suku Bangsa :
6. Status Perkawinan :
7. Pekerjaan :
8. Pendidikan :
9. Status Obstetri :
B. Keluhan Utama
...............................................................................................................................................
C. Riwayat Keluhan Utama
...............................................................................................................................................
D. Riwayat Kesehatan Sekarang
...............................................................................................................................................
E. Riwayat Kesehatan Keluarga
...............................................................................................................................................
F. Genogram

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

G. Riwayat Obstetri
Kehamilan Gangguang Cara Masalah Penolong Masalah Masalah Keadaan
Ke- Kehamilan Persalinan Persalinan Persalinan Nifas Bayi Anak

H. Riwayat Menstruasi
1. Manarche Usia :
2. Siklus Menstruasi : hari, lama menstruasi :
3. Adakah keluhan nyeri haid ? jika ya bagaimana cara mengatasinya :
4. Banyaknya :

I. Keluarga Berencana
1. Jumlah anak yang direncanakan :
2. Jenis kontrasepsi yang pernah digunakan :

No Jenis Kontrasepsi Lama Penggunaan Keluhan Alasan ganti

3. Adakah gangguang atau masalah dengan kontrasepsi tersebut, bila ada

bagaimana cara mengatasisnya

J. Kebutuhan Dasar Khusus :

1. Oksigenasi
.........................................................................................................................................
2. Nutrisi
........................................................................................................................................
3. Cairan
........................................................................................................................................
4. Eliminasi
.........................................................................................................................................
5. Kenyamanan
........................................................................................................................................
6. Pengetahuan
........................................................................................................................................

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

K. Pemeriksaan Fisik (Head To Toe)
1. Antropometri
TB :
BB Sebelum Hamil :
BB Saat ini :
Lingkar Lengan :
2. Tanda Vital :
TD : , Nadi : , Respirasi : , Suhu :
3. Kepala :

4. Mata :

5. Hidung :

6. Telinga :

7. leher :

8. Jantung :

9. Paru-paru :

10. Payudara :

11. Abdomen (secara umum dan pemeriksaan obstetrik)

12. Perianal :
13. Anus :
14. Ekstremitas :
15. Kulit, Kuku :
16. Refleks Patella :

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

L. Pengkajian Psikososial
1. Penerimaan Ibu terhadap penyakitnya
2. Dukungan Keluarga
3. Upaya keluarga dalam menyiapkan kebutuhan
terhadap perubahan peran ibu
4. Bagaimana perasaan ibu dengan perubahan peran
karena proses penyakit dan hospitalisasi ?

J. Pemeriksaan Penunjang
1. Pemeriksaan Laboratorium :
Tanggal, Hasil
2. Pemeriksaan Urinalisis :
Tanggal, Hasil
3. USG :
4. Biopsi Serviks
5. Dll

K. Therapy (Oral, Injeksi, Kemotherapy, dll)

L. Diagnosa Keperawatan :

M. Rencana Tindakan Keperawatan :

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

N. Implementasi Keperawatan :

O. Evaluasi

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

 PRAKTIK KLINIK KEPERAWATAN MATERNITAS
PROGRAM NERS FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

TARGET PENCAPAIAN ANTE NATAL CARE (ANC)

Nama Preseptee : ..................................................................

Nim : ..................................................................
Kelompok : ..................................................................
Tgl. Praktik Selama : ..................................................................
Tempat Praktek : ………………………………………......

Target yang HARUS Jumlah Nama dan Hari / Hasil / Kesimpulan/ Cara Paraf
dicapai Target No.Register Ibu Tanggal Pemeriksaan pada Ibu Hamil Preseptor Klinik
1. TB =
BB =
Pengukuran 2. TB =
1. TB 3 BB =
2. BB
3. TB =
BB =
1.

Pemeriksaan Fisik Ibu 2.

3
Hamil
3.

1.

Melakukan Tindakan 2.
3
Leopold
3.

Penyuluhan Kesehatan
Pada Ibu Hamil
1
(Pendidikan
Kesehatan)
Pengambilan dan
Pembuatan Asuhan
1
Keperawatan Pada Ibu
Hamil

Gorontalo, ..............................
Mengetahui
Preseptor Klinik

(_____________________)

Stase Keperawatan Maternitas Program Profesi NERS FIKES UMGo

Form XII
PRAKTIK KLINIK KEPERAWATAN MATERNITAS
PROGRAM PROFESI NERS FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

TARGET PENCAPAIAN KELUARGA BERENCANA

Nama Preseptee : ..................................................................

Nim : ..................................................................
Kelompok : ..................................................................
Tgl. Praktik : ..................................................................
Tempat Praktek : …………………………………………………
Target yang harus Jumlah Nama dan No.Register Hari / Hasil / Kesimpulan/ Cara Paraf
dicapai Target Ibu Hamil Tanggal Pemeriksaan pada Calon / Preseptor Klinik
Akseptor KB
1.
Pemeriksaan Fisik
2.
Pada Calon / 3
Akseptor KB
3.

1.

Pemberian Pelayanan 2.
3
Kontrasepsi Suntikan
3.

1.

Pemberian Pelayanan 2.
3
Kontrasepsi Pil
3.

Pemberian Pelayanan
Kontrasepsi Lainnya
1
(Sebutkan) ................
.......

Penyuluhan Pada
Calon / Akseptor KB
1
(Pendidikan
Kesehatan)

Gorontalo, ..............................
Mengetahui
Preseptor Klinik

(__________________________)
Form XIII
PROGRAM PROFESI NERS FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

TARGET PENCAPAIAN INTRA NATAL CAREDI KAMAR BERSALIN

Nama Preseptee : ..................................................................
Nim : ..................................................................
Kelompok : ..................................................................
Tgl. Praktik/Puskesmas : ..................................................................
Target yang HARUS Jumlah Nama dan Hari / Hasil / Kesimpulan/ Cara Paraf
dicapai Target No.Register Ibu Tanggal Pemeriksaan pada Ibu Intra Preseptor Klinik
Hamil Natal
1.

Pemeriksaan fisik ibu 2.

3
yang akan melahirkan
3.

1.

Observasi His / 2.
3
Kontraksi
3.

1.

Pengukuran Denyut 2.
3
Jantung Janin
3.

1.

Observasi Tanda- 2.
3
Tanda Vital
3.

1.

2.
Vaginal Touch 3
3.

Menyiapkan alat-alat
1
persalinan klien
Menolong Persalinan
1
yang fisiologis
1.

2.
Memotong Tali Pusat 3
3.

Mengetahui
Preseptor Klinik
(_________________________)

Form XIV
PRAKTIK KLINIK KEPERAWATAN MATERNITAS
 PROGRAM NERS FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

TARGET PENCAPAIAN PASCA NATAL CARE

DI RUANGAN NIFAS
Nama Preseptee : ..................................................................
Nim : ..................................................................
Kelompok : ..................................................................
Tgl. Praktik Selama di PNC : ..................................................................
Puskesmas : …………………………………………………

Target yang HARUS Jumlah Nama dan Hari / Hasil / Kesimpulan/ Cara Paraf
dicapai Target No.Register Ibu Tanggal Pemeriksaan pada Ibu Nifas Preseptor Klinik
Nifas
1.

Pemeriksaan fisik ibu 2.

3
Nifas
3.

1.

Observasi His / 2.
3
Kontraksi
3.

1.

2.
Vulva Higiene 3
3.

1.

Pengukuran Tinggi 2.
3
Fundus Uteri
3.

1.

2.
Breast Care 3
3.

1.

Perawatan Tali Pusat 2.

3
Pada Bayi
3.

1.
Memandikan Bayi 2
2.

Penyuluhan Pada Ibu

Nifas (Pendidikan 1
Kesehatan)
Pengambilan Dan
Pembuatan Asuhan
1
Keperawatan Dengan
Kasus Fisiologis

Gorontalo, ..............................
Mengetahui
Preseptor Klinik

(_________________)

Form XV
 PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

FORMAT KONTRAK BELAJAR

PERIOD
E : PRESEPTEE :
UNIT : KEPERAWATAN DASAR PRESEPTOR :
Sasaran Rencana Kegiatan Metode/Media Target Waktu Persetujuan Preseptor
Belajar/Kompetensi

Form XVI

PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH GORONTALO
 FORMAT RENCANA KEGIATAN HARIAN/MINGGUAN

NAMA
PRESEPTEE :
NAMA
PRESEPTOR :
RUANG/UNIT :
PERIODE :

Minggu Hari Waktu Kegiatan

I

II

III, dst

Form XVII

PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH GORONTALO

FORMAT LOG BOOK

NAMA PRESEPTEE
NAMA PRESEPTOR
RUANG/UNIT
PERIODE
 Rencana Paraf
No Tanggal Aktivity Hasil Yang Kendala Tindak Lanjut Preceptor Preseptor
diperolah Akademik Klinik

Form XVIII
PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH GORONTALO

FORMAT PORTO FOLIO

NAMA PRESEPTEE

RUANG/UNIT
PERIODE
 Paraf
No Komponen & Rinciannya Kesan/Hasil yang diperoleh Nilai
Preseptor Klinik

1. Keterampilan Prosedural

Kejadian luar biasa yang positif

Penghargaan yang diperoleh

Komentar positif dari atasan,

pasien, keluarga pasien, dan
profesi lain

Pelatihan yang diikuti yang

relevan

Pengabdian pada masyarakat

Penelitian yang dilakukan

Seminar ilmiah sebagai

a. Peserta
b. Pembicara
c. Panitia