FORMAT PENGKAJIAN PRAKTEK PROFESI

KEPERAWATAN MATERNITAS
PROGRAM STUDI ILMU KEPERAWATAN
STIKES TUANKU TAMBUSAI

Nama Mahasiswa : Tanggal :

Nim : Ruangan :

A. PENGKAJIAN

1. Identitas Pasien
Nama :
Umur :
Pendidikan :
Suku Bangsa :
Pekerjaan :
Agama :
Status Perkawinan :
Alamat :
No. Medical Record :
Tanggal Pengkajian :
Ruang Rawat :
Golongan Darah :

2. Penanggung Jawab
Nama :
Pekerjaan :
Alamat :

3. Data Saat Masuk Rumah Sakit

Tanggal Masuk :
Jam Masuk RS :
Rujukan :
Diagnosa Medis Masuk :
Ruang Rawat :
Diagnosa Medis Pengkajian :
Alasan Masuk :
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4. Riwayat Kesehatan Sekarang
a. Keluhan Utama
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b. Keadaan Klien Saat Pengkajian
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5. Riwayat Kehamilan dan Persalinan

a. Yang Lalu :
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b. Saat Ini :
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6. Riwayat Kesehatan Keluarga

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7. Riwayat Ginekologi
a. Masalah Ginekologi
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b. Riwayat KB
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8. Riwayat Kesehatan Yang Lalu

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9. Pemeriksaan Fisik Head To Toe

a. Keadaan Umum :
b. Tingkat Kesadaran :
c. Tanda- Tanda Vital :
TD : Suhu :
Nadi : Pernapasan :

d. KEPALA
 Rambut : Panjang / pendek / tanpa rambut / kotor / mudah rontok /
gatal gatal / luka.
Lain-lain:___________________________________________
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Masalah Keperawatan :
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 Mata : Anemis / ikterik / midriasis / pakai kacamata /

contack lens / gangguan penglihatan.
Lain-lain :__________________________________________
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Masalah Keperawatan :
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  Hidung : Perdarahan / sinositis / ggn penciuman / malformasi /
terpasang NGT.
Lain-lain:___________________________________________
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Masalah Keperawatan :
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 Mulut : Kotor / bau / terpasang ETT / gudel / perdarahan / lidah

kotor / luka / ggn pengecapan.
Lain-lain :
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Masalah Keperawatan :
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 Telinga : Perdarahan / terpasang alat bantu dengar / infeksi /

ggn pendengaran.
Lain-lain :
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Masalah Keperawatan :
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e. Leher : Pembesaran KGB / kaku kuduk / terpasang trakeostomi / JVP.

Lain-lain: _____________________________________________
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Masalah Keperawatan :
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f. Dada
1) Jantung
 Inspeksi :
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 Palpasi :
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 Perkusi :
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 Auskultasi :
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2) Paru
 Inspeksi :
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  Palpasi :
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 Perkusi :
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 Auskultasi :
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3) Payudara :
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4) ASI
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g. Tangan: Utuh / luka / lecet / sianosis / capilary refill / clubbing finger / dingin
/ fraktur / edema.
Lain-lain:
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Masalah Keperawatan :
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h. Abdomen
 Inspeksi :
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 Palpasi :
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 Perkusi :
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 Auskultasi :
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i. Genitalia
1) Vagina :
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2) Kebersihan :
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3) Varises :
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4) Keputihan :
Jenis/Warna :__________________________________________________
Konsistensi :__________________________________________________
Bau :__________________________________________________

5) Hemoroid :
Derajat :__________________________________________________
Lama :__________________________________________________
Lokasi :__________________________________________________
Nyeri : Ya / Tidak

Masalah Keperawatan:
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j. Kaki : Utuh / luka / lecet / sianosis / capilary refill / clubbing finger / dingin
/ fraktur / edema.
Lain-lain:
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Masalah Keperawatan:
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k. Eliminasi
1) Urine :
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 2) BAB :
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Masalah Keperawatan:
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l. Istirahat dan Kenyamanan

Keluhan Istirahat dan Tidur :
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Keluhan Ketidaknyamanan : Ya / Tidak, Lokasi :

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Sifat : ______________________________________
Intensitas : ______________________________________

Masalah Keperawatan:
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m. Mobilisasi dan Latihan

Tingkat Mobilisasi : ____________________________________________
Latihan / Senam : ____________________________________________

Masalah Keperawatan:
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n. Nutrisi dan Cairan

Asupan Nutrisi : ____________________________________________
Asupan Cairan : ____________________________________________

Masalah Keperawatan:
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o. Personal Hygiene
1) Mandi : __________________________________________________
2) Gosok Gigi : __________________________________________________
3) Cuci Rambut : __________________________________________________
4) Potong Kuku : __________________________________________________
5) Hambatan Pemenuhan Kebutuhan Higiene :
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 Masalah Keperawatan :
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10. Data Psikologis

Konsep Diri :
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Koping :
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Kecemasan :
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Penerimaan Kondisi Saat Ini :

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Masalah Keperawatan:
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11. Kepercayaan / Kebudayaan Khusus yang Berkaitan dengan Masalah Kesehatan

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12. Catatan Khusus

a. Apakah pasien mengerti tentang penyakit yang dideritanya : Ya / Tidak
b. Apakah ada pertanyaan yang diajukan? Ya / Tidak
c. Jika Ada : ________________________________________________________

Masalah Keperawatan:
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13. Hasil Pemeriksaan Laboratorium dan Diagnostik

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14. Medikasi / Obat-Obatan yang Diberikan Saat Ini / Program Dokter
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B. ANALISA DATA

NO DATA ETIOLOGI MASALAH

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NO DATA ETIOLOGI MASALAH
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C. DIAGNOSA 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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Pekanbaru,.......................
Mahasiswa

( ELIN FITRI )
J. RENCANA ASUHAN KEPERAWATAN
Nama Pasien : Nama Mahasiswa :
Ruangan : NIM :
No.MR :
DIAGNOSA TUJUAN & KRITERIA
NO. INTERVENSI KEPERAWATAN RASIONAL
KEPERAWATAN HASIL
 DIAGNOSA TUJUAN & KRITERIA
NO. INTERVENSI KEPERAWATAN RASIONAL
KEPERAWATAN HASIL
 K. CATATAN KEPERAWATAN DAN PERKEMBANGAN.
Nama Klien :
Diagnosa Medis :
Ruangan :
No. Tanggal/ Evaluasi Tanda
Implementasi
DX Jam (SOAP) Tangan
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No. Tanggal/ Evaluasi Tanda
Implementasi
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