ASUHAN KEPERAWATAN IBU INPARTU

......................................................................................................................................................
Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :

A. DATA SUBYEKTIF
1. IDENTITAS
Nama : Nama Suami :

Umur : Umur :

Agama : Agama :

Pendidikan : Pendidikan :

Pekerjaan : Pekerjaan :

Penghasilan : Penghasilan :

Alamat : Alamat :

No Reg :

Diagnosa Medis :

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

2. KELUHAN
a. Saat MRS
.....................................................................................................................................................................................
.........................................................................................................................................................................................
......................................................................................................................................................................................
b. Saat Pengkajian (Keluhan Utama)

.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
.........................................................................................................................................................................................
 3.2 Penyakit sekarang
.........................................................................................................................................................................................
3.3 Penyakit Keluarga
.........................................................................................................................................................................................
........................................................................................................................................................................................
4. RIWAYAT OBSTETRI / KEBIDANAN
4.1 Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .....................................................................
Menarche :.......................................................... Dismenorhea: .....................................................................
Lama :.......................................................... Flour Albus : .....................................................................
Banyak : ........................................................
Siklus :.........................................................

5. RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU

No Tgl/Bln/Thn Usia Tempat Jenis Penolong Penyulit Anak Nifas Usia Hidup/
JK BB PB
(Gravida) Persalinan Kehamilan Persalinan Persalinan anak Mati

6. RIWAYAT KEHAMILAN SEKARANG

6.1 Riwayat Kehamilan ini : G.....P......................Ab........................

6.2 HPHT :................................ HPL :....................................

6.3 Usia Kehamilan:......................

6.4 Keluhan hamil

muda .....................................................................................................................................................................

........

6.5 Kapan terasa gerakan awal................................................................................................................................

6.6 ANC.....................x, di........................................................................................................................................

6.7 Status TT............................................................................................................................................................

6.8 Terapi yang pernah diberikan..............................................................................................................................

6.9 Penyuluhan yg pernah didapat

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

7. RIWAYAT KB

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

8. RIWAYAT PERNIKAHAN

Usia....................berapa kali.................................

Jarak perkawinan & kehamilan pertama................................................th

9. RIWAYAT PSIKOSOSIAL SPIRITUAL & KELUARGA

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

10. POLA AKTIFITAS

Kebutuhan Dasar Sebelum Hamil Saat Hamil

1. Cairan & Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

6. Pola Sexualitas

B. DATA OBJEKTIF

1. KEADAAN UMUM :

- Kesadaran :.............................................................................................

- TTV :.............................................................................................

- TB :.............................................................................................

- BB (sebelum & saat hamil) :............................................................................................

- Lila :.............................................................................................

2. PEMERIKSAAN FISIK
a. Pemeriksaan Kepala ( Inspeksi, Palpasi)

- Rambut :...............................................................................................................

- Wajah :................................................................................................................

- Mata :................................................................................................................

- Hidung :................................................................................................................

- Mulut :................................................................................................................

- Telinga :................................................................................................................

b. Pemeriksaan Leher :...............................................................................................................

c. Pemeriksaan Thorax (Inspeksi, Palpasi, Auskultasi)

- Payudara

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

- Jantung

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

- Paru

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

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

a. Pemeriksaan Abdomen (Inspeksi, Palpasi, Auskultasi)

Inspeksi :.....................................................................................................................................................................

.......

Palpasi

- Leopold I

:...........................................................................................................................................................................

TFU :........................cm

TBJ :.........................gr

- Leopold II

:...........................................................................................................................................................................

DJJ :.....................................................................................................................................................................

.....
 - Leopold III

:...........................................................................................................................................................................

- Leopold IV

:...........................................................................................................................................................................

b. Pemeriksaan Ekstremitas

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

c.Pemeriksaan Genetalia

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

d. Pemeriksaan Dalam (Vaginal Toucher)

Dilakukan oleh.................................... Tanggal.................................. Jam............................................................

Hasil

:...........................................................................................................................................................................

e. Pemeriksaan Integumen

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

1. PEMERIKSAAN PENUNJANG

- Laboratorium/USG

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

- Radiologi

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

2. TERAPI

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

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

3. KESIMPULAN

G….............P…................Ab……................Usia Kehamilan......................minggu

Inpartu....................................................................................................................................................................................

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

Keterangan:
4. ANALISA DATA
.............................................................................................................................................................................................

NO TANGGAL / JAM ANALISA DATA MASALAH ETIOLOGI

5. DIAGNOSA KEPERAWATAN
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................
.............................................................................................................................................................................................

6. INTERVENSI
..............................................................................................................................................................................................
NO TANGGAL/JA KRITERIA HASIL INTERVENSI RASIONAL
M

NO TANGGAL/JA KRITERIA HASIL INTERVENSI RASIONAL

M
7. IMPLEMENTASI
..............................................................................................................................................................................................

NO TANGGAL/JAM IMPLEMENTASI
NO TANGGAL/JAM IMPLEMENTASI
8. EVALUASI

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

NO TANGGAL/JAM EVALUASI
NO TANGGAL/JAM EVALUASI