LEMBAR PERSETUJUAN

Laporan Pendahuluan dan Asuhan Keperawatan Maternitas

Pada Ibu Dengan ______________ di ___________________________________

telah dikonsultasikan dan disetujui pada tanggal …… April 201.....

Mengetahui,

Pembimbing Akademik Pembimbing Klinik

(………………………………..) (……..………………….........)
 ASUHAN KEPERAWATAN

Nama Mahasiswa :
NIM :

I. PENGKAJIAN
A. DATA UMUM KLIEN

Nama Klien : _______________________________________________

Umur : _______________________________________________
Jenis Kelamin : _______________________________________________
Suku : _______________________________________________
Bangsa : _______________________________________________
Agama : _______________________________________________
Pendidikan : _______________________________________________
Pekerjaan : _______________________________________________
Alamat : _______________________________________________
Tgl MRS : _______________________________________________
Tgl Pengkajian : _______________________________________________
Sumber Informasi : _______________________________________________
Hubungan dengan klien : _______________________________________________
No Register : _______________________________________________
Diagnosa Medis : _______________________________________________

B. STATUS KESEHATAN SAAT INI

1. Keluhan Utama Saat MRS
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2. Keluhan Saat Pengkajian

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3. Riwayat Penyakit Sekarang

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4. Riwayat Keperawatan
a. Riwayat Obstetri
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b. Riwayat Kehamilan, Persalinan, dan Nifas yang lalu

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

Umur
No Tahun Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan

5. Riwayat KB
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6. Riwayat Kesehatan
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7. Riwayat Keluarga
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Genogram
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Keterangan:
: Laki-laki Meninggal
: Wanita Meninggal
: Laki-laki
: Wanita
: Klien
: Garis Keturunan
: Garis Keturunan
: Tinggal Serumah

8. Riwayat Lingkungan Sosial

a. Pola Interaksi dengan keluarga
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b. Hubungan kilen dengan lingkungan sekitarnya

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c. Lingkungan rumah
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9. Kebutuhan Dasar
a. Cairan dan Nutrisi
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b. Pola Istirahat dan Tidur

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c. Personal Higiene
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d. Aktivitas dan Latihan

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e. Pola Kebiasaan Yang Mempengaruhi Kesehatan

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f. Pola Eliminasi
BAB
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BAK
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10. Pemeriksaan fisik

a. Keadaan Umum :
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b. Tanda-tanda Vital :
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c. Kepala-Leher
Inspeksi dan Palpasi
 Kepala :
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 Mata :
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 Hidung :
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 Mulut dan Tenggorok :
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 Telinga :
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 Leher :
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d. Dada
 Thorak :
Inspeksi : _______________________________________________________
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Palpasi : _______________________________________________________
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Perkusi : _______________________________________________________
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Auskultasi : _____________________________________________________
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 Cordis :
Inspeksi :________________________________________________________
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Palpasi : ________________________________________________________
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Perkusi : ________________________________________________________
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Auskultasi : ______________________________________________________
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e. Abdomen:
Inspeksi : _______________________________________________________
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Palpasi : _______________________________________________________
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Perkusi : _______________________________________________________
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Auskultasi : ______________________________________________________
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f. Genetalia-Rektal
Genetalia
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Rektal
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g. Integumen
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h. Ektremitas
 Ekstremitas atas : _________________________________________________
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 Ekstremitas bawah : _______________________________________
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11. Pemeriksaan Penunjang Medis

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12. Diagnosa Medis

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13. Terapi
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II. ANALISA DATA

Ruang :
Nama Pasien :
No. Register :

Data Etiologi Masalah Keperawatan

 III. DAFTAR DIAGNOSA KEPERAWATAN

Ruang :
Nama Pasien :
No. Register :

No Tanggal Diagnosa Keperawatan Tanggal Tanda

Dx Muncul Teratasi Tangan
 IV. RENCANA ASUHAN KEPERAWATAN
Nama Klien : Tgl Pengkajian :
No. Reg : Diagnosa Medis :
No Tgl Diagnosa Keperawatan Tujuan dan kriteria hasil Intervensi
 V. IMPLEMENTASI KEPERAWATAN
Nama Klien :
No. Reg :
Diagnosa
No Tgl Jam Implementasi Evaluasi Hasil
Keperawatan
 VI. CATATAN PERKEMBANGAN KLIEN
Nama Klien : Umur : Tempat Praktek :
No. Reg : Tgl Praktek : Dx Medis :
No. Tgl S O A P I E
Dx