Laporan Kasus

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Oleh:
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SEKOLAH TINGGI ILMU KESEHATAN BULELENG

PROGRAM PROFESI NERS
2021
 Lembar Pengesahan

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Telah disahkan dan diterima oleh Clinical Instruktur (CI) dan Clinical
Teacher (CT) Stase Keperawatan Maternitas sebagai syarat memperoleh nilai
dari Departement Keperawatan Maternitas Program Profesi Ners STIKes
Buleleng.

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Clinical Instructure (CI) Clinical Teacher (CT)
Ruang ............................................. Stase Keperawatan Maternitas
Tempat ............................................. STIKes BULELENG,

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NIP. NIK.
 FORMAT ASUHAN KEPERAWATAN MATERNITAS
”POSTNATAL”

A. PENGKAJIAN
I. Data Umum
1. Nama : ………………………………
2. Usia : ………………………………
3. Pendidikan Terakhir : ………………………………
4. Pekerjaan : ………………………………
5. Agama : ………………………………
6. Suku Bangsa : ……………………………....
7. Status Perkawinan : ………………………………
8. Alamat : ………………………………
Identitas Suami
1. Nama : ………………………………
2. Usia : ………………………………
3. Pendidikan Terakhir : ………………………………
4. Agama : ………………………………
5. Pekerjaan : ………………………………
6. Alamat : ………………………………

II. Riwayat Kesehatan Saat Ini

1. Keluhan utama saat MRS

Jelaskan :...................................................................................................
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2. Keluhan saat pengkajian

Jelaskan :...................................................................................................
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3. Riwayat dirawat

Jelaskan :...................................................................................................
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 4. Riwayat kehamilan, Persalinan, Nifas sekarang
1) Riwayat kehamilan

Jelaskan :............................................................................................
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2) Riwayat persalinan

Jelaskan :..........................................................................................
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3) Riwayat Nifas

Jelaskan :..........................................................................................
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III. Riwayat Kehamilan dan Persalinan Yang Lalu

No Tahun Jenis Penolong Jenis Keadaan Bayi Masalah
Persalinan Kehamilan Waktu Lahir Kehamilan
1
2
3
4
5
Pengalaman menyusui : ya/tidak
Berapa lama :....................................

IV. Riwayat Kehamilan Saat Ini

1. Pemeriksaan kehamilan
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2. Masalah kehamilan
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 V. Riwayat Persalinan
1. Jenis Persalinan
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2. Jenis Kelamin Bayi: L/P, BB: ........... gram, PB: ….… cm,
APGAR: ..........
3. Perdarahan ........... cc
4. Masalah dalam Persalinan .......................................................................

VI. Riwayat Ginekologi

1. Masalah Ginekologi ………………………………………………………...
2. Riwayat Menstruasi
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3. Riwayat KB
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VII. Data Umum Kesehatan Saat Ini

1. Status Obstreti G ....... P …... A …… H ….., UK ............ minggu
2. Keadaan Umum ..................., kesadaran …………........
BB ........ kg, TB ......... cm
3. Tanda Vital
Tekanan Darah ........... mmHg, Nadi ......... x/menit, Suhu ........°C
Pernafasan ......... x/menit
4. Kepala dan Leher
Kepala .......................................................................................................
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Leher .........................................................................................................
5. Dada
Jantung ......................................................................................................
Paru-paru ..................................................................................................
Payudara ...................................................................................................
Pengeluaran ASI .......................................................................................
6. Abdomen
 Involusi Uterus
TFU ............................., kontraksi …....................., posisi …..................
Diastasis rektus abdominis .......................................................................
Kandung kemih .........................................................................................
Fungsi pencernaan ....................................................................................
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7. Perineum dan Genital
Vagina .......................................................................................................
Perineum: Utuh/Episiotomi/Ruptur Tanda REEDA ......................
R : Redness (kemerahan) : ya/tidak
E : Edema (bengkak) : ya/tidak
E : Echimosis (bintik biru) : ya/tidak
D : Discharge (pengeluaran cairan) : serum/pus/darah/tidak ada
A : Aproximation (penyatuan jaringan) : baik/tidak
Kebersihan: ...............................................................................................
Lochea: jumlah ................. cc, jenis/warna .................,
konsistensi ..............., bau ....................
Haemoroid ...............................................................................................
8. Ekstremitas
Ekstremitas atas ........................................................................................
Ekstremitas bawah ....................................................................................
Tanda Homan: +/-, Reflek lutut : +/-
9. Eliminasi
BAK ………………………………………………………….................
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BAB ..........................................................................................................
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10. Istirahat dan Kenyamanan
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11. Mobilisasi dan Latihan
Tingkat mobilisasi
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Latihan/senam
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12. Nutrisi dan Cairan
Asupan nutrisi ...........................................................................................
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Asupan cairan ……………………………………..…….........................
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13. Keadaan Mental
Adaptasi psikologis ...................................................................................
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Penerimaan terhadap bayi .........................................................................
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14. Kemampuan Menyusui
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15. Therapy
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16. Hasil Pemeriksaan Penunjang
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VIII. Rangkuman Hasil Pengkajian

1. Masalah
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2. Perencanaan Pulang
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Analisa Data
Hari/tgl/jam Data Etiologi Masalah

B. DIAGNOSA KEPERAWATAN
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 C. RENCANA KEPERAWATAN

Hari/tgl/jam Diagnosa Tujuan (NOC) Intervensi (NIC) Rasional

Keperawatan

Hari/tgl/jam Diagnosa Tujuan Intervensi Rasional

Keperawatan
 C. IMPLEMENTASI KEPERAWATAN
Hari/tgl/jam No. Dx Implementasi Evaluasi Paraf

Hari/tgl/jam No. Dx Implementasi Evaluasi Paraf

D. EVALUASI
Hari/tgl/jam No. Dx Evaluasi Paraf