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SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

(INSTITUTE OF HEALTH SCIENCES)
BANYUWANGI
Kampus 1 : Jl. Letkol Istiqlah 40 Telp. (0333) 421610 Banyuwangi
Kampus 2 : Jl. Letkol Istiqlah 109 Telp. (0333) 425270 Banyuwangi
Website : www.stikesbanyuwangi.ac.id

LEMBAR PENGKAJIAN
( KEPERAWATAN MATERNITAS / OBSTETRI )

A. IDENTITAS KLIEN
Biodata
a. Nama : ……………………………………………….
b. Umur : ……………………………………………….
c. Jenis Kelamin : ……………………………………………….
d. Alamat : ……………………………………………….
e. Status perkawinan : ……………………………………………….
f. Agama : ……………………………………………….
g. Pendidikan : ……………………………………………….
h. Pekerjaan : ……………………………………………….
i. No. Register : ……………………………………………….
j. Tanggal MRS : ……………………………………………….
k. Tanggal Pengkajian : ……………………………………………….
l. Diagnosa Medis : ……………………………………………….

Biodata Penanggungjawab
a. Nama Suami : ……………………………………………….
b. Umur : ……………………………………………….
c. Pendidikan : ……………………………………………….
d. Pekerjaan : ……………………………………………….
e. Alamat : ……………………………………………….

B. PENGKAJIAN
1. Keluhan Utama
a. Keluhan saat MRS
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b. Keluhan saat Pengkajian

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2. Riwayat Kebidanan Sekarang

a. Riwayat Antenatal/ Kehamilan
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b. Riwayat Intranatal/ Persalinan

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c. Riwayat Post Natal / Nifas

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d. Riwayat Bayi Baru Lahir

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3. Riwayat Kebidanan Masa Lalu

a. Riwayat Haid
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b. Riwayat Perkawinan
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c. Riwayat Kehamilan, Persalinan dan Nifas BBL

Riwayat Kehamilan Persalinan Nifas BBL

Anak Ke

d. Riwayat KB
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e. Kelainan Sistem Reproduksi

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4. Riwayat Kesehatan keluarga

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5. Riwayat Psikososial dan Status Spiritual

1. Kondisi emosi / perasaan klien
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2. Kebutuhan Spiritual Klien :

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3. Tingkat Kecemasan Klien :

No Komponen Yang Cemas Cemas Cemas Panik

dikaji Ringan Sedang Berat
1 Orintasi terhadap □ Baik □ Menurun □ Salah □ Tdk
Orang, tempat,waktu ada reaksi
2 Lapang persepsi □ Baik □ Menurun □ Menyempit □ Kacau
3 Kemampuan □ Mampu □ □Tidak □Tdk
menyelesaikan Mampu deng mampu ada tanggapan
masalah an bantuan
4 Proses Berfikir □ Mampu □ Kurang □Tidak □Alur fikiran
berkonsentrasi mampu mampu kacau
dan mengingat mengingat dan mengingat
dengan baik berkonsentrasi dan
berkonsentras
i
5 Motivasi □ Baik □ Menurun □ Kurang □ Putus asa

6. Pola pemeliharaan kesehatan

1. Pola Pemenuhan Kebutuhan Nutrisi :

Pemenuhan
No Makan/Minum Sebelum Sakit Saat Sakit
Pagi : …………… Pagi : ……………….

Siang : …………. Siang : ……………..

1. Jumlah / Waktu
Malam : ……….. Malam : …………….

Nasi : ………….. Nasi:……………………..

Lauk : ………….. Lauk: …………………….

2. Jenis Sayur : …………. Sayur : …………………..

Minum : ……… Minum/ Infus : ………

Pantangan dan
3.
alergi

Kesulitan Makan
4.
/ Minum

Usaha-usaha
5. mengatasi
masalah
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2. Pola Eliminasi

Pemenuhan
No Sebelum Sakit Saat Sakit
Eliminasi BAB /BAK
Pagi : Pagi :
BAK: ............. BAK: .............
BAB: ............. BAB: ..............

Siang : Siang :
BAK:............ BAK: ............
1 Jumlah / Waktu BAB:............ BAB: ............

Malam : Malam :
BAK: ........... BAK: ............
BAB: ............ BAB: .............

2 Warna
3 Bau
4 Konsistensi
5 Masalah Eliminasi
Cara Mengatasi
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Masalah

3. Pola istirahat tidur

Pemenuhan Istirahat
No Di Rumah Di Rumah Sakit
Tidur
Pagi : ……….. Pagi : …………..

Siang : ……… Siang : ………..

1. Jumlah / Waktu
Malam : ……… Malam : ……….

2. Gangguan Tidur

Upaya Mengatasi
3.
Gangguan tidur
Hal Yang Memper-
4.
mudah Tidur
Hal Yang Memper-
5.
mudah bangun
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4. Pola kebersihan diri / Personal Hygiene :

Pemenuhan Personal
No Di Rumah Di Rumah Sakit
Hygiene
Frekuensi Mencuci
1
Rambut

2 Frekuensi Mandi

3 Frekuensi Gosok Gigi

4 Keadaan Kuku

5. Aktivitas Lain

Aktivitas Yang
No Di Rumah Di Rumah Sakit
Dilakukan

7. Riwayat Sosial ekonomi

1. Latar belakang social dan budaya klien

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2. Ekonomi
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8. Pemeriksaan Fisik

A. PEMERIKSAAN TANDA-TANDA VITAL

1. Tensi : …………… BB : …………………………..
2. Nadi : …………… TB : …………………………..
3. RR : ………………
4. Suhu : ……………… Pasien termasuk : ( Kurus / Ideal / Gemuk )
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B. KEADAAN UMUM

PEMERIKSAAN INTEGUMENT, RAMBUT DAN KUKU

1. Integument
Inspeksi :
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Palpasi :
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2. Pemeriksaan Rambut
Inspeksi dan Palpasi :
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3. Pemeriksaan Kuku
Inspeksi dan palpasi:
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4. Keluhan lain:
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PEMERIKSAAN KEPALA, WAJAH DAN LEHER

1. Pemeriksaan Kepala
 Inspeksi :
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 Palpasi :

2. Pemeriksaan Mata
 Inspeksi :
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3. Pemeriksaan lapang pandang

4. Pemeriksaan Telinga
 Inspeksi dan palpasi

5. Pemeriksaan Hidung
 Inspeksi dan palpasi

6. Pemeriksaan Mulut dan Faring

 Inspeksi dan Palpasi

7. Pemeriksaan Wajah
 Inspeksi :

8. Pemeriksaan Leher
 Inspeksi :

 Palpasi :

 Keluhan lain : ..............................……………………………………………………………

PEMERIKSAAN PAYUDARA DAN KETIAK

 Inspeksi
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 Palpasi
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 Keluhan lain : .............................................................................................……………………...

PEMERIKSAAN TORAK DAN PARU

 Inspeksi
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 Palpasi
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 Perkusi
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 Auskultasi
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 Keluhan lain : ...............................................................................................……………………

PEMERIKSAAN JANTUNG
 Inspeksi
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 Palpasi
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 Perkusi
Batas jantung adalah :
Batas atas : …………………..........
Batas bawah : ……………………..
Batas Kiri : ……………………......
Batas Kanan : ………………..........
 Auskultasi
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 Keluhan lain : …………………………………………................................................................

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PEMERIKSAAN ABDOMEN
1. Inspeksi

2. Auskultasi

3. Palpasi
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 Leopold I : .............................................................................................................
 Leopold II : .............................................................................................................
 Leopold III : ............................................................................................................
 Leopold IV : ............................................................................................................

4. Perkusi :

5. Keluhan lain : .…………...............................................................................................................

PEMERIKSAAN GENETALIA
 Inspeksi
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 Palpasi :

Keluhan lain : .....................................................................................................................................

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PEMERIKSAAN ANUS
 Inspeksi
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 Palpasi
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Keluhan lain : ............................................................................…………………………………

PEMERIKSAAN MUSKULOSKELETAL ( EKSTREMITAS )

 Inspeksi

 Palpasi

Lakukan uji kekuatan otat :

 Keluhan lain : ..............................................................................…………………………………

PEMERIKSAAN NEUROLOGIS
 Menguji tingkat kesadaran dengan GCS ( Glasgow Coma Scale )
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 Memeriksa tanda-tanda rangsangan otak

9. Pemeriksaan Penunjang
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10. Penatalaksanaan
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11. Harapan Klien/ Keluarga sehubungan dengan Penyakitnya

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12. Genogram (3 generasi ke atas)

Banyuwangi, ………, ………….. 20…

Mahasiswa
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ANALISA DATA
Nama Pasien :
No. Register :

NO KELOMPOK DATA MASALAH ETIOLOGI

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ANALISA DATA
Nama Pasien :
No. Register :

NO KELOMPOK DATA MASALAH ETIOLOGI

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DIAGNOSA KEPERAWATAN
Nama Pasien :
No. Register :

TANGGAL TANGGAL TANDA

DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
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RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
No. Register :
TG NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL TT
L
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RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
No. Register :
TG NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL TT
L
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CATATAN KEPERAWATAN
Nama Pasien :
No. Register :
NO T
TANGGAL JAM TINDAKAN KEPERAWATAN
DX T
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CATATAN KEPERAWATAN
Nama Pasien :
No. Register :
NO
TANGGAL JAM TINDAKAN KEPERAWATAN TT
DX
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CATATAN PERKEMBANGAN
Nama Pasien :
No. Register :

NO
TANGGAL TANGGAL TANGGAL
DX
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CATATAN PERKEMBANGAN
Nama Pasien :
No. Register :

NO
TANGGAL TANGGAL TANGGAL
DX