RESUME ASUHAN KEPERAWATAN MATERNITAS (INC)

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

PENGKAJIAN
I. ANAMNESA
1. BIODATA
Nama : ............................................................
Umur : ............................................................
Pekerjaan : ............................................................
Status : ............................................................
Agama : ............................................................
Alamat : ............................................................
Nama suami : ............................................................
Pekerjaan : ............................................................
Alamat : ............................................................
Diagnosa medis : ............................................................
G.............. P............... A............... dengan UK ........................

2. KELUHAN UTAMA
........................................................................................................................................
3. RIWAYAT KESEHATAN
a. Riwayat Penyakit Saat Ini
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
b. Riwayat Kesehatan Masa Lalu
.......................................................................................................................................................
.......................................................................................................................................................
c. Riwayat Kesehatan Keluarga
.......................................................................................................................................................
.......................................................................................................................................................

DATA FOKUS
STATUS OBSTETRI

Palpasi : ..................................................................................................

TFU : ..................................................................................................

DJJ : ..................................................................................................
 Letak anak : ..................................................................................................

Lain- lain : ..................................................................................................

Toucher : Jam................................. Oleh.................................................

Indikasi : ..................................................................................................

Vulva/ vagina : ..................................................................................................

Pembukaan : ..................................................................................................

Efficement : ..................................................................................................

Ketuban : ..................................................................................................

Hodge : ..................................................................................................

Lain- lain/ keadaan luar biasa : .........................................................................................

Partus dipimpin oleh : .................................Dengan pengawasan...............................

Dibantu : ..................................................................................................

KALA I
Tgl/ Pembukaa Frekuens Lama Kuat/
DJJ Keterangan
jam n i His His tidak
 KALA II

TGL/
Lama His DJJ Keterangan
JAM

KU ibu ................................................
∑ perdarahan : ................................
Episiotomi/
tidak : ...........................
Tindakan
lain : ....................................

KALA III
Tgl/ jam His Keterangan

Plasenta : Lengkap/ Tidak Ukuran : .............................................................................

Insertiae : ......................................................... Membran : .............................................

Keadaan luar biasa : .................................................................................................................

Keadaan FU 2 jam post partum : ..............................................................................................

Tanda- tanda Vital : TD .................................. Nadi .....................................

Suhu .............................. RR .....................................

Perineum : ..................................................................................................

Keadaan luar biasa/ lain- lain : ..................................................................................................

 KALA IV

Tgl/ TFU Kontraksi Lochea Keterangan Terapi

jam

ANALISA DATA
No Tanggal/ Data Penunjang MASALAH PENYEBAB
jam
 EVALUASI
N S O A P I E
O
D
X