FORMAT ASUHAN KEPERAWATAN MATERNITAS

“INTRANATAL“

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

DI RUANG ..........................RS ………………………..
PADA TANGGAL ..................................................................

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
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2. Keluhan saat dikaji

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 3. Riwayat keluhan
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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 :

AnakKe Kehamilan Persalinan

No Thn Umur kehamilan Penyulit jenis penolong Penyulit

Komplikasi nifas Anak

Laserasi infeksi Perdarahan Jenis Kelamin BB Pj

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

D. RIWAYAT PENYAKIT
1. Klien
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2. Keluarga
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E. POLA FUNGSIONAL KESEHATAN

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

Kemampuan perawatan diri 0 1 2 3 4

Makan / minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
Ket :
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
5. Oksigenasi
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6. Pola tidur dan istirahat
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7. Pola perseptual
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8. Pola persepsi diri
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 9. Pola seksual dan reproduksi
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10. Pola peran – hubungan
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11. Pola manajemen koping stress
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12. Sistem nilai dan keyakinan
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G. PEMERIKSAAN FISIK
Keadaanumum:
GCS : ..................................................................................................
Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
Tanda – tanda vital
 TD : ..................................................................................................
 Nadi : ..................................................................................................
 Suhu : ..................................................................................................
 RR : ..................................................................................................
BB : ..................................................................................................
TB : ..................................................................................................
LILA : ..................................................................................................

Head toetoe:
1. Kepala
Wajah
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Sclera
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Konjungtiva
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Pembesaran limphe node

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Pembesaran kelenjar tiroid

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 Telinga
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2. Kulit
Lineanigra :( )
Striaegravidarum :( )
Pucat :( )
Cloasma :( )
3. Dada
Payudara : ..................................................................................................
Areola : ..................................................................................................
Putting : ..................................................................................................
Tanda dimpling / retraksi : ..................................................................................................
Pengeluaran ASI : ..................................................................................................
Paru
 Inspeksi : ..................................................................................................
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 Palpasi : ..................................................................................................
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 Perkusi : ..................................................................................................
 Auskultasi : ..................................................................................................
Jantung
 Inspeksi : ..................................................................................................
 Palpasi : ..................................................................................................
 Perkusi : ..................................................................................................
 Auskultasi : ..................................................................................................
4. Abdomen
Linea : ..................................................................................................
Striae : ..................................................................................................
Pembesaran UK : ..................................................................................................
Gerakanjanin : ..................................................................................................
Kontraksi : ..................................................................................................
Luka bekasoprasi : ..................................................................................................
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 : ..................................................................................................
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6. Ekstrimitas
Atas
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Bawah
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H. DATA PENUNJANG
Pemeriksaan laboratorium
Parameter Hasil Satuan Nilai rentang normal
1. Diagnosamedis : ..................................................................................................
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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. Rencana Keperawatan

Jam Diagnosa Tujuan Intervensi Rasional
 RENCANA TINDAKAN KEPERAWATAN KALA 2

No. Tgl / No. Rencana Keperawatan

Jam Diagnosa Tujuan Intervensi Rasional
 RENCANA TINDAKAN KEPERAWATAN KALA 3

No. Tgl / No. Rencana Keperawatan

Jam Diagnosa Tujuan Intervensi Rasional
 RENCANA TINDAKAN KEPERAWATAN KALA 4

No. Tgl / No. Rencana Keperawatan

Jam Diagnosa Tujuan Intervensi Rasional
V. IMPLEMENTASI KEPERAWATAN KALA 1

Hari / No. Tindakan Keperawatan Evaluasi Ttd

Tanggal / Jam Dx.
IMPLEMENTASI KEPERAWATAN KALA 2

Hari / No. Tindakan Keperawatan Evaluasi Ttd

Tanggal / Jam Dx.
 IMPLEMENTASI KEPERAWATAN KALA 3

Hari / No. Tindakan Keperawatan Evaluasi Ttd

Tanggal / Jam Dx.
 IMPLEMENTASI KEPERAWATAN KALA 4

Hari / No. Tindakan Keperawatan 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.
 Denpasar, …………………….20…..

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(…………………….) (…………………….….)
NIP: NIM:

Clinical Teacher/CT 1 Clinical Teacher/CT 2

(…………….……….) (………………..………)
NIP: NIK