LAMPIRAN 3: FORMAT RESUME (Laporan Poli)

A. Identitas Pasien : ......................................................................

.................................................................................................
B. Keluhan Utama : ......................................................................
.................................................................................................
C. Riwayat Penyakit Sekarang : ......................................................
.................................................................................................
D. Riwayat Penyakit Dahulu : .........................................................
.................................................................................................
E. Riwayat Penyakit Keluarga : .......................................................
..................................................................................................
F. Analisa Data
Data Etiologi Problem
DS :
DO :

G. Diagnosa Keperawatan Prioritas

H. Implementasi Keperawatan
No. Tgl /
Implementasi Respon TTd
Dx Jam

I. Evaluasi Keperawatan

No.Dx Tgl / Jam Evaluasi TTd

S:

O:

A:

P:
LAMPIRAN 4:
PENGKAJIAN ASUHAN KEPERAWATAN
WANITA DENGAN PERMASALAHAN REPRODUKSI

Nama Mahasiswa ........................................................................................

Tempat praktek :.......................................................................................
Tanggal :.......................................................................................
I. Identitas diri klien
Nama : ............................................................................
Umur : ............................................................................
Jenis Kelamin : ............................................................................
Agama : ............................................................................
Pendidikan : ............................................................................
Pekerjaan : ............................................................................
Tanggal Masuk R S : ............................................................................
Sumber Informasi : ............................................................................
Keluarga terdekat yang dapat segera dihubungi (Orang tua, wali, suami, istri dll)
...............................................................................................................
Tanggal, jam pengkajian : ......................................................................

II. Status kesehatan saat ini

1. Alasan kunjungan/ keluhan utama
..........................................................................................................
..........................................................................................................
..........................................................................................................
2. Faktor pencetus : .............................................................
3. Lamanya keluhan : .............................................................
4. Timbulnya keluhan :( ) bertahap
( ) mendandak
5. Faktor yang memperberat : .............................................................
6. Upaya yang dilakukan untuk mengatasinya
Sendiri : .............................................................
Oleh orang lain : .............................................................
Diagnosa medik : .......................................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................

III. Riwayat Penyakit Sekarang

..............................................................................................................
 ..............................................................................................................
..............................................................................................................
IV. Riwayat Keluarga
Genogram :

V. Riwayat Kesehatan yang lalu

1. Penyakit yang pernah dialami
.....................................................................................................................................................
.......................................................
2. Alergi : ........................................................................
Tipe...................................Reaksi.....................................................
Tindakan...........................................................................................
3. Imunisasi : .........................................................................
Tipe...................................Reaksi.....................................................
Tindakan...........................................................................................
4. Kebiasaan : Merokok/kopi/obat/alkohol/lain-lain : .........................
5. Obat-obatan : .................................................................................
lamanya : .................................................................................

VI. Pemeriksaan Fisik dan Keluhan Fisik yang Alami

Keadaan umum
Kesadaran :
Vital Sign :
S :
N :
TD :
P :

Kepala
Bentuk....................................................................................................
Keluhan yang berhubungan : pusing/sakit kepala/................................

Mata
Ukuran pupil..........................................................................................
Ukuran akomodasi.................................................................................
Bentuk ...................................................................................................
Konjungtiva............................................................................................
Fungsi penglihatan : baik/kabur/tidak jelas...........................................
Dua bentuk............................................................................................
Tanda-tanda radang...............................................................................
Pemeriksaan mata terakhir....................................................................
Operasi ..................................................................................................
Kaca mata .............................................................................................
Lensa kontak .........................................................................................
Hidung
Reaksi alergi...........................................................................................
Cara mengatasinya.................................................................................
Pernah mengalami flu ...........................................................................
Bagaimana frekuensinya dalam setahun...............................................
Sinus..............................perdarahan .....................................................

Mulut dan tenggorok

Gigi geligi................................................................................................
Kesulitan/ gangguan berbicara..............................................................
Kesulitan menelan.................................................................................
Pemeriksaan gigi terakhir......................................................................
Pernafasan
Suara paru..............................................................................................
Pola nafas...............................................................................................
Batuk .....................................................................................................
Sputum..................................................................................................
Nyeri .....................................................................................................
Kemampuan melakukan aktivitas .........................................................
Batuk darah ...........................................................................................
Rontgen foto terakhir.................................hasil ...................................
Sirkulasi
Nadi perifer............................................................................................
Capilary refiling .....................................................................................
Distensi vena jugularis...........................................................................
Suara jantung ........................................................................................
Suara jantung tambahan .......................................................................
Irama jantung (monitor) .......................................................................
Nyeri .....................................................................................................
Edema....................................................................................................
Palpitasi .................................................................................................
Baal .......................................................................................................
Perubahan warna (kulit, kuku, bibir dll) ................................................
Clubbing ................................................................................................
Keadaan ekstremtitas ...........................................................................
Syncope .................................................................................................
Nutrisi
Berat badan ..........................................................................................
Status gizi ..............................................................................................
Jenis diet ...............................................................................................
Nafsu makan .........................................................................................
Rasa mual ..............................................................................................
Muntah .................................................................................................
Intake cairan .........................................................................................

Eliminisi
BAB
Pola rutin ...............................................................................................
Penggunaan pencahar...........................................................................
Colostomi/ ileostomi..............................................................................
Konstipasi/ obstipasi..............................................................................
Diare .....................................................................................................
BAK
Pola rutin ...............................................................................................
Inkontinensia.........................................................................................
Infeksi....................................................................................................
Hematuri................................................................................................
Kateter...................................................................................................
Urin output............................................................................................
 Reproduksi
Reproduksi : Kehamilan G …. P…. A….
Gg. Proses Lama Tempat Masalah Keadaan
No. Masalah
KehamilPersalin Persalin Persalinan/ Persalina Anak
Anak bayi
an an an penolong n Saat ini

Pemeriksaan payudara..................keluhan payudara...........................

Pemeriksaan genetalia...................keluhan genetalia...........................
Usia menarche.......................................................................................
Siklus menstruasi.................karakteristik menstruasi...........................
...............................................................................................................
Sejak kapan terdiagnosa……………………………………………………………………..
Sudah dilakukan apa…………………………………………………………………………..
Pengaruh perbedaan terhadap kehidupan seksualitas..........................
...............................................................................................................
Pemeriksaan papsmear terakhir............................................................
Hasil.......................................................................................................
Keputihan ..............................................................................................

Neurologis
Tingkat kesadaran................................................GCS...........................
Disorientasi............................................................................................
Tingkah laku...........................................................................................
Riwayat epilepsy/kejang/Parkinson.......................................................
Reflek.....................................................................................................
Kekuatan menggenggam.......................................................................

Musculoskeletal
Kekuatan otot........................................................................................
Pergerakan ekstremitas.........................................................................
Nyeri......................................................................................................
Kekakuan...............................................................................................
Pola latihan gerak..................................................................................

Kulit
Warna....................................................................................................
Integritas................................................................................................
Turgor....................................................................................................

VII. Kesehatan Lingkungan

 Kebersihan : .........................................................................
Bahaya : .........................................................................
Polusi : .........................................................................

VIII. Psikososial
1. Pola pikir dan perspsi
a. Alat bantu yang digunakan
( ) kacamata
( ) alat bantu
Kesulitan yang dialami
( ) sering pusing
( ) menurunnya sensitifitas terhadap sakit
( ) menurunnya sensitifitas terhadap panas/ dingin
( ) membaca/ menulis
2. Perspsi diri
Hal yang sangat dipikirkan saat ini....................................................
Harapan setelah menjalani perawatan ............................................
Perubahan yang dirasa sakit.............................................................
3. Suasana hati ...........................................................................
Rentang perhatian
4. Hubungan/ komunikasi
a. Bicara Bahasa utama
( ) jelas
( ) relevan
( ) mampu mengekspresikan
( ) mampu mengerti orang lain, yaitu .....................................
b. Tempat tinggal
( ) sendiri
( ) bersama orang lain : yaitu ..................................................
Kehidupan keluarga
- Adat istiadat yang dianut : ..............................
- Pembuatan keputusan dalam keluarga : ..............................
- Pola komunikasi : ..............................
- Keuangan : ..............................
( ) memadai
( ) kurang
Kesulitan dalam keluarga
( ) hubungan dengan orang lain
( ) hubungan dengan sanak keluarga
( ) hubungan perkawinan
5. Kebiasaan seksual
 a. Gangguan hubungan seksual disebabkan kondisi seba gai berikut:
( ) Fertilitas ( ) Menstruasi
( ) Libido ( ) Kehamilan
( ) Ereksi ( ) Alat kontrasepsi
b. Pemahaman terhadap fungsi seksual:.........................................
.....................................................................................................
c. Masalah kebiasaan seksual yang dialami :...................................
6. Pertahanan koping
Pengambilan keputusan
( ) sendiri
( ) dibantu orang lain, sebutkan :.................................................
Yang disukai tentang diri sendiri.......................................................
Yang ingin diubah dari kehiduapan...................................................
Yang dilakukan jika stress
( ) pemecahan masalah
( ) makan
( ) tidur
( ) makan obat
( ) cari pertolongan
( ) lain-lain (misal : marah, diam dll) sebutkan :...........................
..........................................................................................................
Apa yang dilakukan perawat agar anda nyaman dan aman.............
..........................................................................................................
7. Sistem nilai – kepercayaan
Siapa apa sumber kekuatan :............................................................
Apakah Tuhan, Agama, kepercayaan itu penting untuk anda:.........
..........................................................................................................
Kegiatan agama atau kepercayaan yang ingin dilakukan selama di rumah sakit, sebutkan :
..........................................................................................................
..........................................................................................................
8. Tingkat perkembangan
Usia............................... Karakteristik..........................
Obat-obatan yang digunakan :
Hari / Waktu
No Nama Obat Dosis Instruksi
Tanggal Pemberian

Hasil Pemeriksaan penunjang :

Tanggal
No Jenis Pemeriksaan Hasil
Periksa
ANALISA DATA
DATA PROBLEM ETIOLOGI
DS :

DO :

DS :

DO :

DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS

1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
4. ...............................................................................................................
5. ...............................................................................................................
INTERVENSI KEPERAWATAN
NO.
NOC NIC
Dx
IMPLEMENTASI KEPERAWATAN
Tgl /
NO.Dx IMPLEMENTASI RESPON TTD
Jam
EVALUASI KEPERAWATAN
NO.Dx Tgl / Jam EVALUASI TTD
S:

O:

A:

P:
LAMPIRAN 5:
PENGKAJIAN ASUHAN KEPERAWATAN PRENATAL

Nama Mahasiswa : ...................... Tanggal Pengkajian : ....................

NIM : ...................... Ruangan/ RS : ....................

DATA UMUM KLIEN

Inisial Klien : ...................................................................................
Usia : ...................................................................................
Status Perkawinan : ...................................................................................
Pekerjaan : ...................................................................................
Pendidikan Terakhir: ..............................................................................
Keluhan Utama : ...............................................................................
...............................................................................................................
Riwayat Penyakit Sekarang : ....................................................................
...............................................................................................................
Riwayat Kehamilan dan Persalinan yang Lalu
Jenis Masalah
No Tahun Penolong BBL Cara Lahir
Kelamin Kehamilan
1
2
3
4
5

Pengalaman menyusui : ya/ tidak Berapa Lama : .......................

Riwayat Ginekologi : .............................................................................
Masalah Ginekologi : .............................................................................
Riwayat KB : .............................................................................
Riwayat kehamilan saat ini
HPHT hamil : .............. TD Sebelum Hamil : .........................
Taksiran Partus : .............. BB Sebelum : .........................
BB Letak/
Usia Data
TD / TFU Presentasi DJJ Keluhan
Gestasi Lain
TB Janin

DATA UMUM KESEHATAN SAAT INI

Status Obstretik : G. . . P . . . A . . .
Keadaan umum : ………. Kesadaran : ………
BB/ TB : ……. Kg/ …….cm
TTV :
TD : ………….mmHg; Nadi :….. x/mnt;
o
Suhu : … C; RR : ….x/ mnt
Kepala-Leher
Kepala : .........................................................................
Mata : .........................................................................
Hidung : .........................................................................
Mulut : .........................................................................
Telinga : .........................................................................
Leher : .........................................................................
Masalah Khusus:
Dada : .........................................................................
Jantung : .........................................................................
Paru : .........................................................................
Payudara : .........................................................................
Putting Susu : .........................................................................
Abdomen : .........................................................................
Uterus
Tinggi fundus uterus : ………cm Kontraksi : ya/ tidak
Lepold I : Kepala/ bokong/ kosong
Lepold II : kanan : punggung/ bagian kecil/ bokong/kepala
Kiri : punggung/ bagian kecil/ bokong/kepala
Lepold III : Kepala/ bokong/ kosong
Penurunan kepala : sudah/ belum
Pigmentasi :
Linea nigra : ada/ tidak
 Striae : ada/ tidak
Fungsi pencernaan : ..........................................................
Masalah khusus : …………………………………….....
Perineum dan genital
Vagina : varises : ya/ tidak
Kebersihan : ...........................................................................
Keputihan : ...........................................................................
Jenis/ warna : ...........................................................................
Konsistensi : ..........................................................................
Bau : ...........................................................................
Hemorrhoid : Derajat : Lokasi :
Berapa lama : Nyeri : ya/ tidak
Ekstremitas
Ekstremitas Atas :
Edema : ya/ tidak, lokasi……………………………...
Kesemutan/ baal
Ekstremitas Bawah :
Edema : ya/ tidak, lokasi
Varises, ya/ tidak, lokasi
Reflek patela : +/ - Jika ada : +1/ +2/ +3
Masalah Khusus : .................................................................
Eliminasi
Urin : Kebiasaan BAK.................................................................
BAB : Kebiasaan BAB.................................................................
Masalah Khusus : ........................................................................
Istirahat dan kenyamanan
Pola tidur : Kebiasaan tidur, lama . . . . jam, frekuensi................
Pola tidur saat ini .......................................................................
Keluhan ketidak nyamanan : ya/ tidak, lokasi ............................
Sifat..............................Intensitas, ..............................................
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 psikologi : ..................................................................
Penerimaan terhadap kehamilan : .............................................
 Masalah khusus :...................................................................
Obat-obatan yang digunakan :
Hari / Waktu
No Nama Obat Dosis Instruksi
Tanggal Pemberian

Hasil Pemeriksaan penunjang :

Tanggal
No Jenis Pemeriksaan Hasil
Periksa

RANGKUMAN HASIL PENGKAJIAN

Masalah:
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

Perencanaan Pulang:
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
ANALISA DATA
DATA ETIOLOGI PROBLEM
DS :

DO :

DS :

DO :

DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS

1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
4. ...............................................................................................................
INTERVENSI KEPERAWATAN
NO.Dx NOC NIC
IMPLEMENTASI KEPERAWATAN
NO. Tgl /
IMPLEMENTASI RESPON TTD
Dx Jam
EVALUASI KEPERAWATAN
NO.Dx Tgl / Jam EVALUASI TTD
S:

O:

A:

P:
Lampiran 6:
PENGKAJIAN ASUHAN KEPERAWATAN INTRANATAL
Nama Mahasiswa : ......................... Tanggal Pengkajian : ...................
NPM : ......................... RS/Ruangan : ...................

I. DATA UMUM
Inisial Klien : ......................................................(… th)
Pekerjaan : ................................................................
Pendidikan Terakhir : ................................................................
Agama : ................................................................
Suku Bangsa : ................................................................
Status Perkawinan : ................................................................
Alamat : ...............................................................
Nama Suami : .......................................................(… th)
Pekerjaan : ...............................................................
Pendidikan Terakhir : ................................................................
Agama : ..............................................................`

II. DATA UMUM KESEHATAN

TB/BB : .............................................cm/kg
BB sebelum hamil : ....................................................kg
Masalah kesehatan khusus : .......................................................
Obat-obatan : .......................................................
Alergi (obat/makanan/bahan tertentu) : .......................................
Diet khusus : ......................................................
Alat bantu yang digunakan : .......................................................
(gigi tiruan/kacamata/lensa kontak/alat dengar)
Lain-lain, sebutkan : .......................................................
Frekuensi BAK, masalah : .......................................................
Frekuensi BAB, masalah : ......................................................
Kebiasaan waktu tidur : ......................................................

III. DATA UMUM OBSTETRI

Kehamilan sekarang direncanakan (ya/tidak) :
Status obstetrik : G … P … A … H ….. Minggu
HPHT : …………………………… Taksiran partus : .....................................
Jumlah anak di rumah :..............................................................
 Jenis BB
No Cara Lahir Keadaan Umur
Kelamin lahir
1
2
3
4
Mengikuti kelas prenatal : (ya/tidak) ...................
Jumlah kunjungan ANC pada kehamilan ini :
Masalah kehamilan yang lalu : ....................................
Masalah kehamilan sekarang : ....................................
Rencana KB : ....................................
Makanan bayi sebelumnya : ASI/PASI/Lainnya : ....
Pelajaran yang diinginkan saat ini : (lingkari) relaksasi//manfaat ASI/senam
nifas/metoda KB/perawatan perineum/perawatan payudara, dan lain-lain, jelaskan:
............................................................................................................
Setelah bayi lahir, siapa yang diharapkan membantu: suami/teman/orang tua:
Masalah dalam persalinan yang lalu : .................................................

IV. INTEGRITAS EGO

Kehamilan yang direncanakan (ya/tidak) : .........................................
Pengalaman melahirkan sebelumnya : ...............................................
Sikap terhadap kehamilan ini :
Klien : ........................................................................
Ayah : ........................................................................
Persepsi ayah terhadap pengalaman melahirkan ibu :........................
Harapan selama persalinan/melahirkan :............................................
Hubungan dengan ayah dari bayi :......................................................
Masalah finansial : .........................................................................
Religius : .........................................................................
Faktor budaya : .........................................................................
Adanya faktor risiko : .........................................................................
Persiapan melahirkan : .......................................................................
Respon terhadap persalinan : (tenang/depresi/gelisah), (cemas/takut/tegang),
(senang/peka/lelah)

V. PERSALINAN SAAT INI

A. PENGKAJIAN AWAL
Tanggal: ……………………………… Jam: ..................................................
Tanda Vital:
TD…………………. mmHg, Nadi…………….. x/menit,
Suhu…..oC, RR ……….. x/menit
Pemeriksaan palpasi abdomen:
Leopold I
………………………………………………………………………………………………………
Leopold II
………………………………………………………………………………………………………
Leopold III
………………………………………………………………………………………………………
 Leopold IV
……………………………………………………………………………………………………..
Hasil periksa dalam ..........................................................................
Persiapan perineum .........................................................................
Dilakukan klisma, (ya/tidak), jelaskan .............................................
Pengeluaran pervaginam ................................................................
Pendarahan pervaginam (ya/tidak), jelaskan ..................................
Kontraksi uterus (frekuensi, lamanya, kekuatan) .............................
Denyut jantung janin (frekensi, kualitas) .........................................
Status janin (hidup/tidak, jumlah, presentasi) .................................

B. PERSALINAN KALA I
Mulai persalinan: tanggal……………………………. Jam............................
Tanda dan gejala
Tanda vital: TD………mmHg, Nadix/menit, Suhu …..C, RR ……… x/menit
Lama kala I ………………….jam ……………………..menit ..................detik
Keadaan psikososial …………………………………………………………………………
………………………………………………………………………………………………………
Kebutuhan khusus klien (jika ada komplikasi baik kehamilan maupun persalinan)

Rangkuman Masalah Pengkajian Kala I

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

ANALISA DATA KALA I

DATA ETIOLOGI PROBLEM
DS :

DO :

DS :

DO :
 DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS KALA I

1.............................................................................................................
2.............................................................................................................
3.............................................................................................................
4.............................................................................................................

INTERVENSI KEPERAWATAN KALA I

NO.Dx NOC NIC
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA I
NO. Tgl /
IMPLEMENTASI EVALUASI TTD
Dx Jam
S:

O:

A:

P:
C. PERSALINAN KALA II
Kala II dimulai: tanggal …………………… jam ........................................
Tanda-tanda vital:
TD ……..mmHg, Nadi ……..x/menit, Suhu …..°C, P ................x/menit
Lama kala II ……………….…jam, ………………… menit,………………….detik
Tanda dan gejala ..............................................................................
Jelaskan upaya meneran ..................................................................
Keadaan psikososial .........................................................................
Kebutuhan khusus ...........................................................................
Rangkuman Masalah Pengkajian Kala II
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

ANALISA DATA KALA II

DATA ETIOLOGI PROBLEM
DS :

DO :

DS :

DO :

DS :

DO :
DIAGNOSA KEPERAWATAN PRIORITAS KALA II
1.............................................................................................................
2.............................................................................................................
3.............................................................................................................
4.............................................................................................................

INTERVENSI KEPERAWATAN KALA II

NO.Dx NOC NIC

IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA II
NO. Tgl /
IMPLEMENTASI EVALUASI TTD
Dx Jam
S:

O:
 A:

P:

D. PERSALINAN KALA III

Tanda dan gejala : .......................................................................
Plasenta lahir jam : .......................................................................
Cara lahir plasenta : .......................................................................
Karateristik plasenta:
Ukuran ………………cm x ………… cm x ............................................cm
Panjang tali pusat.........................................................................cm
Jumlah pembuluh darah …………………… arteri ..........................Vena
Pendarahan ..................................................................................ml
Keadaan Psikososial .........................................................................
Kebutuhan khusus ...........................................................................

Rangkuman Masalah Pengkajian Kala III

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………
ANALISA DATA KALA III
DATA ETIOLOGI PROBLEM
DS :

DO :

DS :

DO :

DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS KALA III

1.............................................................................................................
2.............................................................................................................
3.............................................................................................................
4.............................................................................................................

INTERVENSI KEPERAWATAN KALA III

NO.Dx NOC NIC

IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA III
NO. Tgl /
IMPLEMENTASI EVALUASI TTD
Dx Jam
S:

O:
 A:

P:

E. PERSALINAN KALA IV
Mulai jam .........................................................................................
Tanda vital :
TD .........mmHg, Nadi ………x/menit, Suhu ………. °C, P………x/menit
Kontraksi uterus: baik/tidak ; TFU: ...................................................
Perdarahan (ada/tidak) ……………………ml, Karateristik......................
Vesika urinaria : penuh/tidak
IMD min 1 jam : ya/tidak

Rangkuman Masalah Pengkajian Kala IV

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………
ANALISA DATA KALA IV
DATA ETIOLOGI PROBLEM
DS :

DO :

DS :

DO :

DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS KALA IV

1.............................................................................................................
2.............................................................................................................
3.............................................................................................................
4.............................................................................................................

INTERVENSI KEPERAWATAN KALA IV

NO.Dx NOC NIC

IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA IV
NO. Tgl /
IMPLEMENTASI EVALUASI TTD
Dx Jam
S:

O:
 A:

P:

VII. BAYI
Bayi lahir tanggal/jam ...........................................................................
Jenis kelamin .........................................................................................
Nilai APGAR ...........................................................................................
BB/PB/lingkar kepala bayi ………….gram ……………….cm ....................cm
Karateristik khusus bayi ........................................................................
Kaput: suksedaneum/cephalhematom .................................................
Suhu ………..°C
Anus berlubang/tertutup ......................................................................
Perawatan tali pusat .............................................................................
Perawatan mata ....................................................................................
Pemberian vit K ya/tidak
Obat-obatan yang digunakan :
Hari / Waktu
No Nama Obat Dosis Instruksi
Tanggal Pemberian

Hasil Pemeriksaan penunjang :

Tanggal
No Jenis Pemeriksaan Hasil
Periksa
Lampiran 7:
FORMAT PENGKAJIAN BAYI BARU LAHIR
Nama Mahasiswa : ……………….. Rumah Sakit :………………..
Nama Ayah - Ibu : ……………….. Tanggal Pengkajian :………………..
Alamat : ……………….. Jam Pengkajian : ……………….

I. RIWAYAT KELAHIRAN YANG LALU

Tahun BB Keadaan Jenis
No Sex Komplikasi Ket
Kelahiran lahir Bayi Persalinan
1
2
3
4
5
6
7
8
9
10

Pemeriksaan antenatal : teratur/ tidak teratur

Komplikasi antenatal...........................................................................
II. RIWAYAT PERSALINAN
BB/ TB Ibu : .........kg/..............cm Persalinan di ..................................
Keadaan umum ibu........................ Tanda vital....................................
Jenis persalinan.............................. Proses persalinan.........................
Kala I .................................jam
Indikasi :...............................................................................................
Lamanya ketuban pecah...........................kondisi ketuban..................
III. KEADAAN BAYI SAAT LAHIR
Lahir tanggal :............................ jam..................sex................................
Kelahiran : tunggal/ gemeli
NILAI APGAR
Nilai
Tanda Jml
0 1 2
Denyut jantung () O tidak ada () O < 100 () O > 100
Usaha nafas () O Tidak ada () O Lambat () O Menangis
kuat
Tonus otot () O Lumpuh () O Ektremitas () O Gerakan
fleksi aktif
sedikit
Iritabilitas () O tidak () O Gerakan () O Reaksi
berekasi sedikit melawan
tubuh
Refleks Warna () O Biru/ () Kemerahan () O Kemerahan
pucat tanga dan
kaki biru
Ket : () Penilaian menit ke-1 O Penilaian menit ke-5
Tindakan resusitaasi :.................................................................................
Pasenta berat :..................................... Tali Pusat : panjang.......................
Ukuran.................................................. Jumlah pembuluh darah..............
Kelainan ..................................................kelainan......................................
PENGKAJIAN FISIK
Umur...........................Hari/ Tanggal ...............................Jam.......................

Berat Badan....................................Gr MULUT O Simetris

Panjang Badan................................Cm O Palatum mole
Suhu............................................... 0c O Palatum durum
Lingkar Kepala................................Cm O Gigi
Lingkar Dada...................................Cm HIDUNG O Lubang hidung
Lingkar Perut..................................Cm O Keluran
KEPALA O Pernafasan
Bentuk O Bulat O Cuping hidung
O Lain-Lain LEHER O Pergerakan leher
Kepala O Molding TUBUH
O Kaput Warna O Pink
O Chapalhematom O Pucat
Ubun-Ubun Besar....................... O Sianosis
Kecil........................ O Kuning
Sutura..................... Pergerakan O Aktif
MATA Posisi....................... O Kurang
O Kotoran DADA O Simetris
O Perdarahan O Asimetris
TELINGA Posisi.................................. O Retraksi
 Bentuk................................ O Seesaw
O Lubang telinga STATUS NEUROLOGI
O Keluran Reflex O Tandon
Jantung dan paru-paru O Normal (nilai semua) O Moro
Bunyi nafas O Ngorok O Roting
O Lain-lain O Mengisap
Pernafasan.......................x/ menit O Babinski
Denyut jantung................x/ menit O Menggenggam
Perut O Lembek O Menangis
O Kembung O Berjalan
O Benjolan O Tonus leher

Bising usus...........x/ menit NUTRISI

Lanugo............................................... Jenis makanan O ASI
Vernix................................................ OPASI
Mekonium......................................... Lain-lain.................................
PUNGGUNG ELIMINASI
Keadaan Punggung O Simetris BAB pertama,
O Asimetris tanggal.......jam.....
O Pilonidal Dimple BAK pertama,
Fleksibilitas tanggal.......jam.....
Tl. Punggung O Kelainan..............

Genitalia O Normal TULANG

O Hipospadia Lingkar Kepala.....................cm
O Epispadius Dada....................................cm
Testis.................................................. Perut ..................................cm

PEREMPUAN DATA LAIN YANG MENUNJANG

Labia minora O Menonjol (lab, psikososial, dll)
O Tertutup
KESIMPULAN :
Labia Mayor
Keluaran.................
O Kelainan..............
EKSTREMITAS
Jari tangan O Kelainan
Jari kaki O Kelainan
Pergerakan O Tidak ada
O Asimetris
O Tremor
O Rotasi paha
Nadi Brachial............................
Femoral............................
Garis telapak kaki...............................
Posisi kaki .........................................
Tangan...............................................
Keterangan :
 Bayi baru lahir yang dikaji berusia < 24 jam
 Observasi keadaan umum dan tanda-tanda vital ibu, kontraksi uterus (frekuensi dalam 10 menit/
interval, lama, intensitas/ kekuatan, relaksasi), djj, penurunan kepala, lengkapi patograf.
 Periksa dalam II (PD II) 4 jam berikutnya : Bila tiba-tiba keluar air ketuban, ibu diistirahatkan. Bila
mungkin biarkan ibu memilih posisi sesuai dengan keinginannya (setengah duduk, menungging,
jongkok atau berbaring pada sisi kiri)
 Darah dan lender keluar semakin banyak, vulva hygiene sebelum PD II. Ceritakan tanda-tanda
kala II/pembukaan lengkap.
 Hasil PD II
- Porsio tidak teraba, pembukaan lengkap, ketiban (+), menonjol
- Kepala hodge IV
 Pengawasan janin
Letak presentasi, posisi, penurunan presentasi, djj (frekuensi, intensitas dan keteraturan.
 Rangkuman Masalah Pengkajian Bayi Baru Lahir:
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………….

IV. ANALISA DATA :

No Data Fokus Etiologi Masalah

1. DS :

DO:
 2. DS :

DO :

3. DS :

DO :

V. DIAGNOSA KEPERAWATAN PRIORITAS:

1 ............................................................................................................
2 ............................................................................................................
3 ............................................................................................................
4 ............................................................................................................

INTERVENSI KEPERAWATAN

NO
NOC NIC
DX
1

2
3
IMPLEMENTASI KEPERAWATAN

NO TGL / IMPLEMENTASI RESPON PARAF

DX JAM KEPERAWATAN KLIEN
EVALUASI KEPERAWATAN

NO TGL /
CATATAN PERKEMBANGAN PARAF
DX JAM
Lampiran 8:
FORMAT PENGKAJIAN POSTPARTUM
Nama Mahasiswa : ……………….. Tanggal Pengkajian :………………..
NIM : ……………….. Ruangan/ RS :………………..

I. BIODATA KLIEN
Inisial klien : .................. Initial Suami : ..................
Usia :................... Usia : ..................
Staus Perkawinan :................... Staus Perkawinan : ..................
Pekerjaan :................... Pekerjaan : ..................
Pendidikan Terakhir :................... Pendidikan Terakhir : ..................
No. RM : ..................
Keluhan Utama: ................................................................................................................
................................................................................................................
Riwayat Penyakit Dahulu
..........................................................................................................................................................
..........................................................................................................................................................
...........................
Riwayat Penyakit Sekarang
: .........................................................................................................................................................
..........................................................................................................................................................
.............................
Riwayat Penyakit Keluarga
: .........................................................................................................................................................
..........................................................................................................................................................
............................
Riwayat Kehamilan dan persalinan yang lalu
Pengalaman menyusui : ya/ tidak Berapa lama : .........................

Riwayat kehamilan saat ini

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 : ...................................................................
Riwayat Ginekologi
Masalah Ginekologi :...............................................................................
Riwayat KB : ...........................................................................................
II. Data Umum Kesehatan saat Ini
Status Obstetri : P..... A ...... bayi Rawat gabung : ya/ tidak
Jika tidak alasannya .............................................................................
Keadaan umum : ………..... Kesadaran : ………................................. BB : ……. Kg, TB : …….cm
Tanda vital : Tekanan Darah : ……….mmHg; Nadi ………x/menit,
Suhu : ………….oC, Pernafasan : ………….x/ menit
Kepala – Leher
Kepala :........................................................
Mata :........................................................
Hidung :........................................................
Mulut :........................................................
Telinga :........................................................
Leher :........................................................
Masalah Keperawatan.........................................................:
Dada
Jantung :........................................................
Paru :........................................................
Payudara :........................................................
Putting Susu :........................................................
Penyaluran ASI :........................................................
Kemampuan Menyusui :........................................................
Masalah Keperawatan :........................................................
Abdomen :........................................................
Strie Gravidarum : Ada / tidak
Linea Nigra : Ada / tidak
Involusi uterus
Fundus uterus : ...........................Kontraksi : .............Posisi..............
Kandung kemih
Diastasis Rektus abdominis : ..............jari
Fungsi pencernaan
Masalah Keperawatan...................................................................
Perineum dan genital
Vagina : Integritas kulit.................edema.....memar................
Hematom..................................
Perineum : Utuh/ episiotomi/ ruptur/ tanda REEDA
R (Red) : Kemerahan : ya/ tidak
E (Edema) : Bengkak : ya/ tidak
E (Echimosis) : Echimosis : ya/ tidak
D (discharge) : Serum/ pus/ darah/ tidak ada
A (Approxiamate) : Baik/ tidak
Kebersihan Perineum...........................................................................
Lochea : ..............................
Jumlah :.......................cc, Jenis warna :...........................
Konsistensi :..................., Bau :...........................
Hemorrhoid : Ada / tidak. Derajat : Lokasi :
Berapa lama : Nyeri : ya/ tidak

Ekstremitas
Homan Sign : +/-
Ekstremitas Atas : Edema : ya/ tidak, Kesemutan/ baal : ya/ tidak
Ekstremitas Bawah : Edema : ya/ tidak, lokasi.............................
Varises, ya/ tidak, lokasi...............................................................
Reflek patela : +/ -
Masalah Keperawatan :
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, frekwensi...........
Pola tidur saat ini....................................................................
Keluhan ketidak nyamanan : ya/ tidak, lokasi ..................................
Sifat .....................................................Intensitas, ...........................
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 : ...................................................
Masalah khusus :...............................................................

Obat-obatan yang digunakan :

No Hari / Nama Obat Dosis Instruksi Waktu
 Tanggal Pemberian

Hasil Pemeriksaan penunjang :

Tanggal
No Jenis Pemeriksaan Hasil
Periksa

III. Rangkuman Hasil Pengkajian

Masalah :
................................................................................................................
................................................................................................................
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Perencanaan Pulang :
................................................................................................................
................................................................................................................
................................................................................................................

IV. ANALISA DATA :

No Data Fokus Etiologi Masalah

1. DS :

DO:
 2. DS :

DO :

3. DS :

DO :

V. PRIORITAS DIAGNOSA KEPERAWATAN:

1 ............................................................................................................
2 ............................................................................................................
3 ............................................................................................................
4 ............................................................................................................
INTERVENSI KEPERAWATAN
Nama Klien : ........................... Usia :........ thn
Status Obstetri : P..... A ......
Tgl Persalinan : .............................. Tgl Pengkajian : ..................

NO
NOC NIC
Dx. Kep
1

3
IMPLEMENTASI KEPERAWATAN
Nama Klien : ........................... Usia :........ thn
Status Obstetri : P..... A ......
Tgl Persalinan : .............................. Tgl Pengkajian : ..................

NO TGL / IMPLEMENTASI RESPON PARAF

DX JAM KEPERAWATAN KLIEN
EVALUASI KEPERAWATAN

NO TGL /
CATATAN PERKEMBANGAN PARAF
DX JAM