FORMAT ASUHAN KEPERAWATAN MATERNITAS

“POST NATAL”

ASUHAN KEPERAWATAN PADA Ny...... DENGAN.........................................

DI RUANG NIFAS (DAHLIA) RSAD DENPASAR
PADA TANGGAL ..... s.d ..... Desember 2018

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :.....................................................................................................
Umur :.....................................................................................................
Pendidikan :.....................................................................................................
Pekerjaan :.....................................................................................................
Status perkawinan :.....................................................................................................
Agama :.....................................................................................................
Suku :.....................................................................................................
Alamat :.....................................................................................................
No. CM :.....................................................................................................
Tanggal MRS :.....................................................................................................
Tanggal Pengkajian :.....................................................................................................
Sumber informasi :.....................................................................................................

PENANGGUNG/ SUAMI
Nama :.....................................................................................................
Umur :.....................................................................................................
Pendidikan :.....................................................................................................
Pekerjaan :.....................................................................................................
Alamat :.....................................................................................................

B. ALASAN DIRAWAT
1. Alasan MRS
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2. Keluhan saat dikaji
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C. RIWAYAT OBSTERTRI DAN GINOKOLOGI

a. Riwayat Menstruasi
 Menarche : Umur.......................................................................................................
 Banyaknya : ................................................................................................................
 Keluhan :.................................................................................................................
  HPHT :.................................................................................................................
 Siklus : teratur ( _ ) tidak ( _ )
 Lamanya : ................................................................................................................

b. Riwayat Pernikahan
 Menikah : ............... kali
 Lama : ............... tahun

c. Riwayat kelahiran, persalinan, nifas yang lalu

Anak ke Kehamilan Persalinan

No. Tahun Umur kehamilan Penyulit Jenis Penolong Penyulit

Komplikasi nifas Anak

Leserasi Infeksi Pendarahan Jenis kelamin Berat badan Panjang

d. Riwayat Keluarga Berencana

Akseptor KB:
 Jenis : ................................................................................................................
 Lama : ................................................................................................................
 Masalah : ................................................................................................................
 Rencana KB : ................................................................................................................

D. POLA FUNGSIONAL KESEHATAN

Pemeliharaan dan persepsi terhadap kesehatan
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Nutrisi
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Pola eliminasi
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Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4
Makan/ minum
Mandi
Toileting
Berpakaian
Mobilisasi ditempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total.

Oksigensi
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Pola Tidur dan istrahat

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Pola perceptual
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Polapersepsi diri
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Pola seksual dan reproduksi

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Pola peran-hubungan
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Pola manajemen koping stress

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Sistem nilai dan keyakinan

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E. PEMERIKSAAN FISIK
1. Keadaan umum : ....................................................................................................
2. GCS : ....................................................................................................
3. Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
4. Tanda-tanda vital
 Tekanan darah : ....................................................................................................
 Nadi : ....................................................................................................
 Respirasi : ....................................................................................................
 Suhu : ....................................................................................................
5. BB : ....................................................................................................
6. TB : ....................................................................................................
7. LILA : ....................................................................................................

Head to toe
KepalaWajah
 Inspeksi
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 Palpasi
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Leher
 Inspeksi
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 Palpasi
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Tubuh
 Warna : ........................................................................................
 Lanugo : ........................................................................................
 Vernix : ........................................................................................
Dada
 Inspeksi : ........................................................................................
 Palpasi : ........................................................................................
 Perkusi : ........................................................................................
 Auskultasi : ........................................................................................
Abdomen
 Linea : ........................................................................................
 Satriae : ........................................................................................
 TFU : ........................................................................................
 Kontraksi : ........................................................................................
 Diastasi rectus abdominis : ........................................................................................
 Bising usus : ........................................................................................
Genetalia
 Kebersihan : ........................................................................................
 Lokhea : ........................................................................................
 Krakteristik : ........................................................................................

Perineum dan anus

 Perineum
R (red) : ........................................................................................
E (edema) : ........................................................................................
E (echymosis) : ........................................................................................
D (discharge) : ........................................................................................
A (approximation) : ........................................................................................
 Hemoroid : ........................................................................................
Ekstremitas
 Atas
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 Bawah
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F. DATA PENUNJANG

Parameter Hasil Satuan Nilairentang normal

Pemeriksaan Radiologik :
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G. DIAGNOSA MEDIS
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H. PENGOBATAN

Nama Obat Dosis Rute Indikasi

II. ANALISA DATA

DATA ETIOLOGI PROBLEM

III. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan
Prioritas
 NO TANGGAL / DIAGNOSA KEPERAWATAN TANGGAL Ttd
JAM TERATASI
DITEMUKAN

IV. Rencana Tindakan Keperawatan

Hari/ No RencanaPerawatan Ttd
 TujuandanKriteriaHa
Tgl Dx Intervensi Rasional
sil

V. Implementasi Keperawatan
Hari/ No Ttd
Tindakan Keperawatan Evaluasi proses
Tgl/Jam Dx
VI. Evaluasi Keperawatan
Hari/Tgl No
Evaluasi TTd
Jam Dx