FORMAT PENGKAJIAN

KEPERAWATAN MATERNITAS
PROGRAM STUDI PROFESI NERS PERIODE ANTENATAL CARE (ANC)
FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS NUSA NIPA
MAUMERE
2022

Tanggal MRS :
No. reg ( CM ) : Diagnosa medis :..............................................
Pengkajian tanggal : Jam pengkajian :.............................................

I. IDENTITAS
 IBU ( ISTRI )  SUAMI (PENANGGUNGJAWAB)
Nama : ............................ Nama : ............................
Umur : ............................. Umur : .............................
Pekerjaan : ............................. Pekerjaan : .............................
Suku/bangsa : ............................. Suku/bangsa : .............................
Agama : ............................. Agama : .............................
Alamat : ............................. Alamat : .............................
Status perkawinan : ............................. Status perkawinan : .............................

II. KELUHAN UTAMA :

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III. RIWAYAT KESEHATAN
1. Latar belakang kunjungan
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2. Riwayat kesehatan keluarga
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3. Penyakit terdahulu yang mempengaruhi kehamilan
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4. Penyakit yang sedang dialami
klien .........................................................................................................................................
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IV. RIWAYAT OBSTETRI (Nomor 2-7 untuk multigravida)
1. Riwayat Haid :
a. HPHT : ............................................ TTP: ..................................................
b. Siklus Haid : ...........................................................................................................
c. Lamanya : ............................................................................................................
d. Banyaknya : .............................................................................................................
e. Masalah : .............................................................................................................
2. Riwayat kontrasepsi :
a. Metode : .................................................................................
b. Kapan menggunakan :..................................................................................
c. Tujuan :..................................................................................
d. Masalah : ..................................................................................
e. Kapan berhentinya : ..................................................................................
f. Alasan berhenti : ..................................................................................
g. Rencana KB yang akan digunakan : ..................................................................................
3. Riwayat kehamilan terdahulu :
a. Gravida………….. Partus……………….. Abortus……….
b. Jumlah anak yang hidup : Laki – laki ……org, Perempuan …..... org
c. Interval kelahiran : ............................................................................
d. Penolong persalinan lalu : ............................................................................
e. Tempat melahirkan : ............................................................................
4. Komplikasi yang terjadi pada waktu kehamilan yang lalu :
HT oedema ISK perdarahan antepartum persalinan premature
Hyperemesis gravidarum pre eklampsi eklampsi diabetes
Lainnya…………..............................................................................................................
5. Komplikasi waktu persalinan dan kelahiran yang lalu :
SC perdarahan kejang Distosia Partus Lama
Lainnya …………............................................................................................................
6. Masalah pada waktu masa nifas :
Perdarahan infeksi anemia lain – lain.....................................................
7. Masalah pada bayi yang dilahirkan :
Asfiksia gangguan menetek ikterus BBLR
Lahir mati / fetal dead cacat Lainnya, .................................

V. RIWAYAT PENGOBATAN / MEROKOK / ALKOHOL

a. Obat yang digunakan : ............................................................................
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b. Tujuan pengobatan : ............................................................................
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 c. Cara pemberian : ............................................................................
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d. Ketergantungan dengan rokok : ............................................................................
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e. Ketergantungan dengan alkohol : ............................................................................
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f. Jenis imunisasi yang telah diberikan : ............................................................................
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g. Waktu pemberian : ............................................................................
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VI. MASALAH YANG DIRASAKAN KLIEN
Nausea Vomitus Gangguan Miksi Sakit Ulu Hati Kram Pada Kaki
Perdarahan Kejang Nyeri Perut Lelah Sakit Pinggang
Lainnya…………..........................................................................................................................

VII. DATA PSIKOLOGIS

a. Status Psikologis : ...............................................................................................................
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b. Status Perkawinan
 Usia Saat Kawin : ...............................................................................................................
 Perkawinan Yang Ke : .............................................................................................................
 Lama Perkawinan : ...............................................................................................................
c. Reaksi Dan Persepsi Kehamilan
 Direncanakan : Ya / Tidak
 Diharapkan : Ya / Tidak
 Dilanjutkan : Ya / Tidak
 Menerima / Tidak Menerima, alasan : ...................................................................................
 Jenis anak yang diharapkan : Laki – Laki / Perempuan
 Siapa yang paling penting bagi klien : ..................................................................................
 Rencana tempat melahirkan : .................................................................................
 Rencana mengikuti senam hamil : Ya / Tidak
 Rencana Meneteki Sendiri : Ya / Tidak
d. Kebutuhan pendidikan kesehatan
 Informasi persalinan : ya / tidak ...................................………......................................
 Breast care : ya / tidak ...................................………......................................
 Personal higiene : ya / tidak ...................................………......................................
 Nutrisi dalam kehamilan : ya / tidak ...................................………......................................
 Perawatan bayi : ya / tidak ...................................………......................................
 Latihan dan aktifitas : ya / tidak ...................................………......................................
 Kegiatan seksual : ya / tidak ...................................………......................................
 Komplikasi ringan dan upaya mengatasinya : : ya / tidak ...................................……….......

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  KB : ya / tidak ...................................………......................................

VIII. PEMERIKSAAN FISIK

1. Tanda – tanda Vital :
Tekanan darah : ……mmHg
Suhu : ……. celcius
Nadi : ……..x/menit
RR : ………x/menit
2. Berat Badan Sebelum Hamil : …………… Kg, Tinggi Badan :…………cm
Berat Badan Saat Hamil : .................... Kg
LiLA : .................... cm
3. Kulit :
Ikterik hiperpigmentasi
Kemerahan Lainnya, ...............….........................................................................................
 Kloasma Gravidarum : ……………………………………………………………………….
 Turgor :...............................................................................................................
 Kelembaban : ...............................................................................................................
 Luka / iritasi : ...............................................................................................................
 Pelebaran vena : ...............................................................................................................
4. Payudara
Areola Mammae : ..............................................................................................................................
Putting : Menonjol / Datar / Masuk
Colustrum : .............................................................................................................................
5. Abdomen
 Pembesaran : ya / tidak
 Bentuk perut : ...............................................................................................................
 Linea nigrae : ...............................................................................................................
 Striae : ...............................................................................................................
 Luka / iritasi / Bekas Operasi : ...............................................................................................
 Jaringan parut : ..............................................................................................................
 Palpasi
Leopold I : ...............................................................................................................
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...
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.
Leopold II : ...............................................................................................................

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 ..................................................................................................................................................
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...
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Leopold III : ...............................................................................................................

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...
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Leopold IV : ...............................................................................................................
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...
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 Mc Donald Rule : …………….cm
 Auskultasi ( O / O ) : ...............................................................................................................
Frekuensi (DJJ) : ...............................................................................................................
Regularitas ; ...............................................................................................................
Lokalisasi : ...............................................................................................................
 Pergerakan anak : Ya / Tidak, Jumlah .................. x/hari (N : >10x dlm 12 jam)
6. Panggul luar ( untuk primipara ) :
 Distansia spinarum :.................... cm
 Distansia cristantia : .................... cm
 Bouledoque : .................... cm
 Lingkar panggul : .................... cm
7. Ekstremitas ( atas dan bawah ) :
 Ukuran telapak kaki : ......................................................................................................
 Warna kuku : ......................................................................................................
 Oedema : ......................................................................................................
 Varices : ......................................................................................................
 Reflex tungkai bawah : ......................................................................................................

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 8. Vulva
 Oedema : ...............................................................................................................
 Varices : ...............................................................................................................
 Luka : ...............................................................................................................
 Pengeluaran cairan : ya / tidak, Jika Ya, warna ……..................... bau ……........................
 rectum : varices Ya Tidak
Haemoroid Ya Tidak

IX. PEMERIKSAAN PENUNJANG

N Hasil Satua
Tanggal Pemeriksaan Kriteria Nilai Normal
o Pemeriksaan n

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 X. TERAPY
Cara
Dosis Kontra
TgL No Terapi Pemberia Indikasi
(Kandungan Obat) Indikasi
n

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XI. ADL
NO STATUS SEBELUM HAMIL SAAT HAMIL
NUTRISI :
Menu makanan
1 Porsi
Pantangan
Keluhan
CAIRAN:
Jenis minuman
2 Porsi
Pantangan
Keluhan
BAB :
Frekuensi
Konsistensi
Warna/bau
keluhan
3
BAK :
Frekuensi
Konsistensi
Warna/bau
keluhan
AKTIVITAS
Kegiatan
4 sehari – hari
Keterbatasan
Kemampuan otot

Asuhan Keperawatan Maternitas_ANC |8

 Keluhan
ISTIRAHAT
TIDUR :
Pola tidur
5
Waktu ..
Gangguan tidur

Keluhan
Personal
Hygiene
Mandi

Keramas

6 Gosok gigi

Ganti pakaian

Vulva hygiene

Keluhan

Seksualitas

7 Perubahan pola

Jenis perubahan

Keluhan

......................., ………………… 20… Mengetahui,

Pengkaji, CI Ruang ...................................

(______________________________) ( ________________________ )

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 B. KLASIFIKASI DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................

DATA SUBYEKTIF :
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DATA OBYEKTIF : (Termasuk Hasil Pemeriksaan Fisik, Monitoring, dan Pemeriksaan Penunjang)

Asuhan Keperawatan Maternitas_ANC | 10

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C. ANALISA DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem (NANDA)

Asuhan Keperawatan Maternitas_ANC | 11

 D. DIAGNOSA KEPERAWATAN :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................

PRIORITAS MASALAH KEPERAWATAN :

1. .............................................................................................................................................

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2. .............................................................................................................................................

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3. .............................................................................................................................................

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4. .............................................................................................................................................

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 5. .............................................................................................................................................

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6. .............................................................................................................................................

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7. .............................................................................................................................................

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8. .............................................................................................................................................

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E. PATOFLOW KASUS :

Asuhan Keperawatan Maternitas_ANC | 13

 Contoh Format
F. RENCANA KEPERAWATAN SALIN di lembar bagian tengah
Double Folio Bergaris

NAMA KLIEN : .............................................. NAMA MAHASISWA : ............................

NIRM : .............................................. PROGRAM : ............................
DIAGNOSA MEDIS : ............................................. INSITITUSI : ............................
BANGSAL / TEMPAT : ............................................................

KONFIRMASI AK
DATA TUA
DIAGN
L/
OSA TUJUAN
RES
KEPER DAN RENCANA KEPERAWATAN
N REKA IKO
TGL AWATA KRITERI (NIC)
o M PASIE / PK
N A HASIL DAN RASIONAL
MEDI N /
(NANDA (NOC)
K WE
)
LLN
ESS
1 ....
Pemeri DS : R/ ....
ksaan 2. ...
Penunja R/ ....
ng: DO : Dst..
 Lab,  Obser- (Berdasarkan ONEC, yaitu
Ront vasi  Observation (Observasi)
gen,  PemFi  Nursing (Tindakan Mandiri
Ct s Perawat)
Scan  Education (Pendidikan
, Kesehatan)
MRI,  Collaboration (Kolaborasi
dsb. Medis, Paramedis, dan
Keluarga)
Monito
ring

Pedoman Program PendidikanProfesi Ners 2021/2022

 Contoh Format
SALIN di lembar bagian tengah
Double Folio Bergaris
G. IMPLEMENTASI

NAMA KLIEN : .............................................. NAMA MAHASISWA : ............................

NIRM : .............................................. PROGRAM : ............................
DIAGNOSA MEDIS : ............................................. INSITITUSI : ............................
BANGSAL / TEMPAT : ............................................................

IMPLEMENTASI PARAF
EVALUASI
Tgl / Jam PELAKSANAAN Mahasiswa CI / CT

S:
O:
A:
P:

Pedoman Program PendidikanProfesi Ners 2021/2022