FORMAT ASUHAN KEPERAWATAN MATERNITAS

“ INTRANATAL“

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

DI RUANG VK (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 JAWAB
Nama : ....................................................................................................
Umur : ....................................................................................................
Pendidikan : ....................................................................................................
JenisKelamin :.....................................................................................................
Pekerjaan :.....................................................................................................
Alamat :.....................................................................................................
Status Perkawinan :.....................................................................................................
Agama :.....................................................................................................

B. DATA KESEHATAN
1. Keluhan Utama
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

2. Keluhan saat dikaji

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 3. Riwayat keluhan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

C. RIWAYAT OBSTETRI DAN GINEKOLOGI

1. Riwayat menstruasi:
 Menarche : ....................................................................................................
 Banyaknya : ....................................................................................................
 Siklus : teratur ( ) tidak ( )
 Lama : ....................................................................................................
 Keluhan : ....................................................................................................
 HPHT : ....................................................................................................
2. Riwayat pernikahan
 Menikah : ……….. kali
 Lama : ……….. tahun
3. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak Ke Kehamilan Persalinan

No Thn Umur kehamilan Penyulit jenis penolong Penyulit

Komplikasinifas Anak
Laserasi infeksi Perdarahan Jenis Kelamin BB Pj

4. Riwayat kehamilan sekarang

Status Obstetrikus :
 G….. P….. A…... H…..
 UK : ………. ....minggu
 TP : ………...................
 ANC kehamilan sekarang
....................................................................................................................................
....................................................................................................................................
…………………………………………………………………………………….....
 Trimester I : .......................................................................................................
.........................................................................................................
.........................................................................................................
.........................................................................................................
Trimester II : .......................................................................................................
.........................................................................................................
.........................................................................................................
.........................................................................................................
Trimester III : .......................................................................................................
.........................................................................................................
.........................................................................................................
.........................................................................................................
.........................................................................................................
5. Riwayat keluarga berencana
 Akseptor KB..............................................................................................:
..
 Jenis : ....................................................................................................
 Lama : ....................................................................................................
 Masalah : ....................................................................................................

D. RIWAYAT PENYAKIT
1. Klien
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2. Keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

E. POLA FUNGSIONAL KESEHATAN

1. Pemeliharan dan persepsi terhadap kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2. Nutrisi / metabolic
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
3. Pola eliminasi
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4

Makan / minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempattidur
Berpindah
Ambulasi ROM
Ket : 0:mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total

5. Oksigenasi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Pola tidur dan istirahat
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
7. Pola perseptual
..........................................................................................................................................
..........................................................................................................................................
...........................................................................................................................................
8. Pola persepsi diri
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
9. Pola seksual dan reproduksi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
10. Pola peran – hubungan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
11. Pola manajemen koping stress
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
12. Sistem nilai dan keyakinan
..........................................................................................................................................
..........................................................................................................................................

G. PEMERIKSAAN FISIK
Keadaan umum:
GCS : ....................................................................................................
Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
Tanda – tanda vital
 TD : ....................................................................................................
 Nadi : ....................................................................................................
 Suhu : ....................................................................................................
 RR : ....................................................................................................
BB : ....................................................................................................
TB : ....................................................................................................
LILA : ....................................................................................................

Head toe toe:

1. Kepala
Wajah
.................................................................................................................................................
.................................................................................................................................................

Sclera
.................................................................................................................................................

Konjungtiva
.................................................................................................................................................

Pembesaran limphe node

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

Pembesaran kelenjar tiroid

 .................................................................................................................................................
Telinga
.................................................................................................................................................
.................................................................................................................................................

2. Kulit
Linea nigra :( )
Striae gravidarum :( )
Pucat :( )
Cloasma :( )
3. Dada
Payudara : .....................................................................................................
Areola : .....................................................................................................
Putting : .....................................................................................................
Tanda dimpling / retraksi : .....................................................................................................
Pengeluaran ASI : .....................................................................................................
Paru
 Inspeksi : .....................................................................................................
.....................................................................................................
.....................................................................................................
 Palpasi : .....................................................................................................
.....................................................................................................
 Perkusi : .....................................................................................................
 Auskultasi : .....................................................................................................
Jantung
 Inspeksi : ....................................................................................................
 Palpasi : ....................................................................................................
 Perkusi : ....................................................................................................
 Auskultasi : ....................................................................................................
4. Abdomen
Linea : ....................................................................................................
Striae : ....................................................................................................
Pembesaran UK : ....................................................................................................
Gerakan janin : ....................................................................................................
Kontraksi : ....................................................................................................
Luka bekas oprasi : ....................................................................................................
Ballottement : ....................................................................................................
Leopold I : Kepala / bokong / kosong
 TFU : ....................................................................................................
Leopold II
 Kanan : Punggung / bagian kecil / bokong / kepala
 Kiri : Punggung / bagian kecil / bokong / kepala
Leopold III : Presentasi kepala / bokong / kosong
Leopold IV : Bagian masuk PAP (konvergen / divergen / sejajar)
Penurunan kepala : ....................................................................................................
Kontraksi : ....................................................................................................
DJJ : ....................................................................................................
 Bising usus : ....................................................................................................
5. Genetalia dan perineum
Kebersihan : ....................................................................................................
Pengeluaran : ....................................................................................................
Karakteristik : ....................................................................................................
Hemoroid : ....................................................................................................
Hasil VT : ....................................................................................................
......................................................................................................
6. Ekstrimitas
Atas
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Bawah
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

H. DATA PENUNJANG
Pemeriksaan laboratorium
Parameter Hasil Satuan Nilai rentang normal

1. Diagnosa medis : ....................................................................................................

......................................................................................................
......................................................................................................
 2. Terapi
Nama Obat Dosis Rute Indikasi

II. ANALISA DATA KALA 1

DATA ETIOLOGI PROBLEM

ANALISA DATA KALA 2

DATA ETIOLOGI PROBLEM

ANALISA DATA KALA 3

DATA ETIOLOGI PROBLEM

ANALISA DATA KALA 4

DATA ETIOLOGI PROBLEM

III. TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN KALA 1

NO TANGGAL/ DIAGNOSA KEPERAWATAN TANGGAL TTD

JAM TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN KALA 2

NO TANGGAL/ DIAGNOSA KEPERAWATAN TANGGAL TTD

JAM TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN KALA 3

NO TANGGAL/ DIAGNOSA KEPERAWATAN TANGGAL TTD

JAM TERATASI
Ditemukan
 TABEL MASALAH KOLABORATIF/DIAGNOSA KEPERAWATAN KALA 4

NO TANGGAL/ DIAGNOSA KEPERAWATAN TANGGAL TTD

JAM TERATASI
Ditemukan
IV. RENCANA TINDAKAN KEPERAWATAN KALA 1

No. Tgl / No. RencanaKeperawatan

Jam Diagnosa Tujuan Intervensi Rasional
RENCANA TINDAKAN KEPERAWATAN KALA 2

No. Tgl / No. RencanaKeperawatan

Jam Diagnosa Tujuan Intervensi Rasional
RENCANA TINDAKAN KEPERAWATAN KALA 3

No. Tgl / No. RencanaKeperawatan

Jam Diagnosa Tujuan Intervensi Rasional
RENCANA TINDAKAN KEPERAWATAN KALA 4

No. Tgl / No. RencanaKeperawatan

Jam Diagnosa Tujuan Intervensi Rasional
V. IMPLEMENTASI KEPERAWATAN KALA 1

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal / Jam Dx.
IMPLEMENTASI KEPERAWATAN KALA 2

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal / Jam Dx.
IMPLEMENTASI KEPERAWATAN KALA 3

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal / Jam Dx.
IMPLEMENTASI KEPERAWATAN KALA 4

Hari / No. TindakanKeperawatan Evaluasi Ttd

Tanggal / Jam Dx.
VI. EVALUASI KEPERAWATAN KALA 1

No. Hari / tanggal / No. Evaluasi Ttd

Jam Dx.

EVALUASI KEPERAWATAN KALA 2

 No. Hari / tanggal / No. Evaluasi Ttd
Jam Dx.

EVALUASI KEPERAWATAN KALA 3

 No. Hari / tanggal / No. Evaluasi Ttd
Jam Dx.

EVALUASI KEPERAWATAN KALA 4

No. Hari / tanggal / No. Evaluasi Ttd
Jam Dx.