STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

PENGKAJIAN PRENATAL

Nama Mahasiswa : ……………… Tgl. Pengkajian :……………………..

Stambuk : ……………….. Ruangan/RS : ...............................

DATA UMUM KLIEN

1. Inisial Klien :
2. Usia :
3. Status perkawinan :
4. Pekerjaan :
5. Pendidikan :
Riwayat Kehamilan dan Persalinan yang lalu
No. Tahun Jenis Penolong Jenis Kelamin Keadaan Bayi Masalah
persalinan waktu lahir kehanmilan

1.
2.
3.
4.
5.
Pengalaman menyusui eksklusif: ya/tidak Berapa lama :
Riwayat Ginekologi
1. Masalah ginekologi :
2. Riwayat KB :
Riwayat Kehamilan saat ini
HPHT :............................ Taksiran partus :.......................................
BB sebelum hamil :........................... TD sebelum hamil :........................................
TD BB/TD TFU Letak/presentasi DJJ Usia Gestasi Keluhan Data
janin lain

DATA UMUM KESEHATAN SAAT INI

Status obstetrik : G... P... A... H.... minggu
Keadaan umum :...................Kesadaran :.......................BB/TB :...................Kg/cm
Tanda Vital
Tekanan Darah:.............mmHg; Nadi:....................Suhu:............... ºC
Pernapasan : ...............x/mnt

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Kepala Leher
Kepala : ................................................................................
Mata : ................................................................................
Hidung : .................................................................................
Mulut : .................................................................................
Telinga : .................................................................................
Leher : .................................................................................
Masalah Khusus : .................................................................................
Dada
Jantung : ................................................................................
Paru : .................................................................................
Payudara : .................................................................................
Puting susu : .................................................................................
Pengeluaran ASI : ................................................................................
Masalah Khusus : .................................................................................
Abdomen
Uterus
TFU :....................cm kontraksi : ya/tidak
Leopold I : kepala/bokong/kosong
Leopold II : kanan : punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/bokong/kepala
Leopold III : kepala/bokong/kosong
Leopold IV : bagian masuk PAP
Pigmentasi
Linea nigra :
Striae:
Fungsi pencernaan :
Masalah Khusus : .................................................................................
Perineum dan Genital
Vagina : vrises; ya/tidak
Kebersihan :…….
Keputihan :
Jenis/warna :.............Konsistensi : ................... Bau : .......................
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :......................................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Refleks patela : +/- jika ada : +1/+2/+3
Masalah khusus : ………………………………………………………
Eliminasi
Urin : kebiasaan BAK……………………………………………
Fekal : kebiasaan BAB.............................................................
Masalah Khusus :.....................................................................................
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ..................................................................................
Nutrisi dan Cairan
Asupan nutrisi (frekuensi dan porsi makan jenis makanan)
............................................................
Nafsu makan : baik/kurang/tidak ada
Asupan cairan : .................cc/hari, jenis.................................................
Masalah khusus : ....................................................................................
Seksualitas
Frekuensi: ..............................................................................................
Posisi: ....................................................................................................
Masalah Khusus:....................................................................................
Dukungan suami/keluarga terhadap kehamilan:
.............................................................................................................................................................................................
.......................................................................
Keadaan Mental
Adaptasi psikologis : ...............................................................................
Penerimaan terhadap kehamilan :...........................................................
Masalah khusus : ...................................................................................

Pola hidup yang meningkatkan risiko

kehamilan : .................................................................................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

..................................................................................................................................
Persiapan Persalinan
□ Senam hamil
□ Rencana tempat melahirkan
□ Kesiapan biaya persalinan
□ Perlengkapan kebutuhan bayi dan ibu
□ Kesiapan mental ibu dan keluarga
□ Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses persalinan
□ Perawatan payudara

Obat-obatan yang dikonsumsi saat ini :

Hasil pemeriksaan penunjang :

RANGKUMAN HASIL PENGKAJIAN

................................................................................................................................
.................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
..............................................................................................................................................

Perencanaan Kunjungan Rumah :

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

PENGKAJIAN INTRANATAL

Nama Mahasiswa : ............................ Tanggal Pengkajian : ..............................

NIM : .............................................. RS/Ruangan :..........................................
I. DATA UMUM
Inisial klien : ................ (.....th) Nama Suami : .............................(......th)
Pekerjaan : ............................... Pekerjaan : .............................................
Pendidikan Terakhir : .............. Pendidikan terakhir :.............................
Agama : ................................... Agama : .............................................
Suku bangsa :......................
Status perkawinan : ......................................................
Alamat : .........................................................................................................

II. DATA UMUM KESEHATAN

TB/BB : ................cm/.................kg
BB sebelum hamil : .....................kg
Masalah kesehatan khusus : ...........................................................................
Obat-obatan : .................................................................................................
Alergi (obat/makanan/bahan tertentu) : .........................................................
Diet khusus : ..................................................................................................
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain-lain : .......................................................................................................
Frekuensi BAB/BAK :...................................................................................
Masalah BAB/BAK : ........................................................................................
Kebiasaan waktu tidur : ...................................................................................

III. DATA UMUM KEBIDANAN

Kehamilan sekarang direncanakan (ya/tidak)*
Status Obstetri : G ...........P.............A ............H ..............(minggu)
HPHT : .................................Taksiran partus : ................................................
Jumlah anak di rumah : ..............................................
No Jenis kelamin Cara lahir BB Lahir Keadaan saat ini Umur

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Mengikuti kelas prenatal (ya/tidak) : ..............

Jumlah kunjungan ANC pada kehamilan ini : .......................................
Masalah kehamilan yang lalu : .........................................................................
Masalah kehamilan sekarang : .......................................................................
Rencana KB : .............................
Makanan bayi sebelumnya : ASI/PASI/lainnya*
Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi,/pernafasan/manfaat ASI/cara memberi minum botol/senam nifas/metode KB/perawatan
perineum/perawatan payudara/lain-lain,
jelaskan .......................................................................................................................
Setelah bayi lahir, siapa yang diharapkan membantu : ..................................
Masalah dalam persalinan yang lalu : .............................................................
IV. RIWAYAT PERSALINAN SEKARANG
Mulai persalinan (kontraksi): tanggal/jam : ............................
Pengeluaran pervaginam (tanggal/jam) : ...............................
Keadaan kontraksi (frekuensi dalam 10 menit, lamanya,
kekuatannya) : ............................................................................................................................................................
.........................................................................................
Denyut jantung janin : Frekuensi ...................................
Kualitas : ...................................
Irama : .......................................
Pemeriksaan fisik :
Kenaikan BB selama hamil : .....................kg
TTV : TD......................mmHg,N.......................x/mnt S............... oC P..............x/mnt
Kepala dan leher :......................................................................(normal/tidak)
Jantung : .........................................................................................................
Paru-paru : ......................................................................................................
Payudara : .......................................................................................................
Abdomen : (secara umum dan pemeriksaan obstetrik) : ................................
..........................................................................................................................
Ekstremitas : edema/tidak ...............................................................................
Refleks : ..........................................................................................................
Pemeriksaan dalam pertama : (jam) .......................oleh : ..............................
Hasil : ..................................... ........................................................................
Ketuban : (utuh/pecah), jika sudah pecah : tgl/jam :.....................................
warna.............................................
Laboratorium : .................................................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

V. DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : ...............................................................
Perasaan klien terhadap kehamilan sekarang : ..............................................
Perasaan suami terhadap kehamilan sekarang : .............................................
Jelaskan respon sibling terhadap kehamilan sekarang : ................................

LAPORAN PERSALINAN
I. Pengkajian awal
Tanggal : .........................Jam : ............................
TTV : TD......................mmHg,N.......................x/mnt S............... oC P..............x/mnt
Pemeriksaan palpasi abdomen
Leopold I : ..............................................................................
Leopold II : . ..............................................................................
Leopold III : ..............................................................................
Leopold IV : ..............................................................................
Hasil pemeriksaan dalam : ...............................................................................
Pemeriksaan perineum : .................................................................................
Dilakukan klisma (ya/tidak) : .............
Pengeluaran pervaginam : …………………………………………………….
Perdarahan pervaginam: tidak/ ya, jumlah ………………ml
Kontraksi uterus (frekuensi, lamanya, kekuatan) : ..........................................
DJJ : (frekuensi/kualitas)................................./................................................
Status janin : (hidup/tidak,jumlah,presentasi) : ...............................................
..........................................................................................................................

II. Kala persalinan

Kala I
Mulai persalinan : (tanggal/jam).......................................................................
Tanda dan gejala : ...........................................................................................
Lama Kala I : (jam/menit/detik)........................................................................
Keadaan psikososial : ......................................................................................
Kebutuhan khusus klien : .................................................................................
Tindakan : .......................................................................................................
Pengobatan : ....................................................................................................

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 STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Observasi kemajuan persalinan :

Tanggal/jam Periksa Dalam Kontraksi uterus DJJ Keterangan

Kala II
Kala II dimulai : (Tgl/jam) : ..............................................................................
TTV : TD......................mmHg,N.......................x/mnt S............... oC P..............x/mnt
Lama kala II : (jam/menit/detik) ........................................................................
Keadaan psikososial : ......................................................................................
Kebutuhan khusus klien : .................................................................................
Tindakan : .......................................................................................................
Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur : .......................
Bonding ibu dan bayi :.......................
TTV bayi : TD......................mmHg,N...............x/mnt S............... oC P..............x/mnt
Pengobatan : ....................................................................................................
Catatan kelahiran :
Bayi lahir jam : .......................................
Jenis kelamin : ........................................
Nilai APGAR menit I................................menit V...........................
BB/PB/lingkar kepala : ......................gram.........................cm....................cm
Karakteristik khusus bayi : ...............................................................................
Kaput suksadaneum/cephal hematoma : .........................................................
Anus : berlubang/tertutup*
Perawatan tali pusat :..............................................................
Perawatan mata : ...................................................................
Kala III
Mulai jam : .................
TTV : TD......................mmHg,N.......................x/mnt S............... oC P..............x/mnt
Tanda dan gejala :............................................................................................
Plasenta lahir jam : ..........................................................................................
Cara lahir plasenta :.........................................................................
Karakteristik plasenta .....................................................................
Diameter : ..........cm

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Ketebalan : .............cm
Panjang tali pusat : ..........................................................................
Jumlah pembuluh darah :.........................arteri .......................vena
Insersio tali pusat : ..........................................................................
Kelainan : ........................................................................................
Pengeluaran darah per vaginam : .........................ml
Karakteristik perdarahan : ...............................................................
Keadaan psikososial : ......................................................................
Kebutuhan khusus : .........................................................................
Tindakan : .......................................................................................
Pengobatan : ....................................................................................

Kala IV
Mulai jam : ................
TTV : TD......................mmHg,N.......................x/mnt S............... oC P..............x/mnt
Kontraksi uterus : ............................................................................................
Pengeluaran darah per vaginam :......................ml
Karakteristik : ..................................................................................................
Tindakan : .....................................................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

FORMAT PENGKAJIAN BAYI BARU LAHIR

Nama : By.
Tempat Tgl. Lahir :
Umur :
Jenis kelamin :
Kondisi Umum :
TTV :

Riwayat kelahiran
- BB : .......................
- Panjang badan : .......................
- Suhu : .......................
: .......................
- Lingkar Kepala
: .......................
- Lingkar dada : .......................
- Masalah dalam proses
kelahiran : .......................
- Lanugo : ........................
- Vernix kaseosa : ........................
- Mekonium : ........................
: ........................
- Warna tubuh
: ........................
- APGAR Score menit I : .......................
Menit V
- Usia gestasi :.......................

Pemeriksaaan Reflek
- Reflek moro : ...........................
- Reflek menggegam : ...........................

- Reflek menghisap
: ..........................
- Reflek tonik neck : ..........................
- Tonus otot/aktivitas : ..........................

- Kekuatan menangis : ..........................

Pemeriksaan Fisik
a. Kepala
- Bentuk kepala : ................................
- Ubun-ubun : .................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

- Mata
- Telinga : ..................................
:...................................
- Hidung
:...................................
- Mulut
: Reflek menelan dan menghisap....., labioskhisis
( ), palatoskisis ( ), sianosis ( )
b. Punggung
- Keadaan punggung
: Lecet ( ),Lordosis ( ), scoliosis ( ), kiposis ( )

: ................................
- Fleksibelitas tulang punggung

c. Thorak : .......................
- Bentuk dada : .......................
- Jenis pernapasan : .......................
- Frekuensi napas
d. Abdomen
- Bentuk abdomen : .......................

- Bising usus : .......................

e. Ekstremitas
- Jari kaki : ...........................
: ...........................
- Jari tangan
: ...........................
- Pergerakan kaki
: ...........................
- Pergerakan tangan
: ...............................
- Garis telapak kaki
: ...............................
- Warna ekstremitas : ...............................
- Posisi ekstremitas

f. Alat Reproduksi /Genitalia :.....................................

- laki-laki (penurunan testis,
ukuran)

- perempuan (labia minora, :.....................................

mayora, keluaran)

:Frekuensi BAK......... warna.........

g. Fungsi Eliminasi

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

- Fungsi miksi :Frekuensi BAB .........

Konsistensi ...... Warna .......
- Anus
Diagnosa Medis

Pola Fungsi Kesehatan bayi

1. Nutrisi dan metabolisme :

2. Istirahat dan tidur :

3. Aktifitas dan latihan :

4. Lainnya :

Ballard’s Score :

Obat-obatan yang diberikan:

Pemeriksaan Lab:

Kesimpulan:

PENGKAJIAN POST PARTUM

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Nama Mahasiswa :..................................... Tanggal Pengkajian :..........................

Stambuk : .................................... .. Ruangan/RS : .........................

DATA UMUM KLIEN

1. Inisial klien Inisial Suami
2. Usia Usia
3. Status perkawinan Status perkawinan
4. Pekerjaan Pekerjaan
5. Pendidikan terakhir Pendidikan terakhir
Riwayat Kehamilan dan Persalinan Yang Lalu
No. Tahun Tipe Penolong Jenis BB lahir Keadaan bayi Masalah kehamilan
Persalinan kelamin waktu lahir

Pengalaman menyusui eksklusif: ya/tidak berapa lama :

Riwayat Kehamilan saat ini

1. Berapa kali periksa kehamilan
2. Masalah kehamilan
Riwayat Persalinan
1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV,EF)
SC ......................... Tgl/jam :...............
2. Jenis kelamin bayi : L/P, BB/PB :........gram/......cm,
3. Pengeluaran darah per vaginam :...........................cc
4. Masalah dalam persalinan ..................................................
Riwayat Ginekologi
1. Masalah ginekologi
2. Riwayat KB

DATA UMUM KESEHATAN SAAT INI

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Status obstetrik : P.... A..... NH... Bayi Rawat Gabung : Ya/tidak

Jika tidak, alasan : ..........................................
Keadaan umum :..................... Kesadaran :.......................... ..BB/TB ...........Kg/cm
Tanda Vital
Tekanan Darah:.............mmHg; Nadi:....................Suhu:............... ºC
Pernapasan : ...............x/mnt
Kepala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah Khusus : ...............................................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI :
Masalah Khusus : ................................................................................
Abdomen
Involusi Uterus
Fundus Uteri :....................kontraksi : .................Posisi :......................
Kandung kemih
Diastasis rektus abdominis ......................x......................cm
Fungsi pencernaan :
Masalah Khusus : .................................................................................
Perineum dan Genital
Vagina : integritas kulit.....edema.....memar.....hematom.........
Perineum : Utuh/episiotomi/ruptur Tanda REEDA
R : Kemerahan : ya/tidak
E : Edema : ya/tidak
E : Ekimosis : ya/tidak
D : Dischargeserum/pus/darah/tidak ada
A : Approximate : baik/tidak
Kebersihan :…….

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Lokia :
Jumlah : ............Jenis/warna :..............Konsistensi : .............Bau : .....
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :.....................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Tanda Homan : +/-
Masalah khusus : ……………………………………………..............
Eliminasi
Urin : kebiasaan BAK……………………………………………
BAK saat ini......................................nyeri/tidak
Fekal : kebiasaan BAB.............................................................
BAB saat ini.............................konstipasi/tidak :
Masalah Khusus :...................................................................................
Istirahat dan Kenyamanan
Pola tidur : kebiasaan tidur, lama...jam, frekuensi............
Pola tidur saat ini.................
Keluhan ketidaknyamanan : ya/tidak, lokasi................
Sifat....................intensitas...........................
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ........................................................................
Nutrisi dan Cairan
Asupan nutrisi : ....................nafsu makan : baik/kurang/tidak ada
Asupan cairan : ...................................cukup/kurang
Masalah khusus : ............................................................................

Keadaan Mental

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Adaptasi psikologis : .....................................................................

Penerimaan terhadap bayi :...........................................................
Masalah khusus : ...........................................................................
Kemampuan menyusui: .................................................................................
Obat-obatan yang dikonsumsi saat ini :

Hasil pemeriksaan penunjang :

RANGKUMAN HASIL PENGKAJIAN

Masalah :
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................

Perencanaan Pulang :
..................................................................................................................................
..................................................................................................................................
...............................................................................................................................

PENGKAJIAN KELUARGA BERENCANA

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Nama mahasiswa : ……………………Tanggal pengkajian :………………………

NIM : ………………………………........ Ruangan/RS : ………………………………
I. Data umum klien :
Initial klien : ......................................................................................................
Usia : ...............................................................................................................
Status perkawinan : ........................................................................................
Pekerjaan : .....................................................................................................
Agama : ..........................................................................................................
Suku bangsa : .................................................................................................
II. Data umum kesehatan saat ini
TB/BB : ................................................cm/ .................................................kg
Keadaan umum : ...........................................................................................
Tanda-tanda vital : TD : ………mmHg, N : ………x/mnt
P : ............x/mnt, S : .................. oC
Kepala dan rambut :
Bentuk kepala : ………………………………………………………………….
Keadaan rambut : ……………………………………………………………….
Kebersihan rambut : ……………………………………………………………
Wajah/muka : ………………………………………………………………………
Mata :
Konjungtiva : ……………………………………………………………………
Sclera : …………………………………………………………………………..
Gangguan penglihatan : ……………………………………………………….
Hidung : …………………………………………………………………………….
Mulut : ……………………………………………………………………………..
Telinga : ……………………………………………………………………………
Leher : ………………………………………………………………………………
Dada :Payudara : ……………………………………….......................................
Abdomen : …………………………………………………………………………..
Genitalia : ……………………………………………………………………………
Tungkai bawah : …………………………………………………………………….
III. Data umum kebidanan
Status obstektrik : P.............A ...........

Jumlah anak di rumah :

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Jenis
No Umur Cara persalinan BB lahir Keadaan sekarang
kelamin
1
2
3
4
5
6

Alasan datang ke klinik : ……………………………..................................................

Lama perkawinan : …………………………………………….....................................
Masalah untuk hamil : …………………………………………....................................
Masalah selama kehamilan : ……………………………….......................................
Masalah setelah melahirkan : ……………………………………...............................
Riwayat penggunaan metode kontrasepsi (hormonal/non hormonal):
No. Jenis Kontrasepsi Tahun s/d Tahun Masalah Pemakaian Alasan Penghentian
Pemakaian

Cara KB yang diminati saat ini: ..............………………..........................................

Riwayat sosial : .......................................................................................................
Persetujuan/Sikap suami terhadap Metode Kontrasepsi yang
dipilih: ................................................................................................................................
................................................................................................................................
Pengetahuan tentang berbagai metode kontrasepsi (pengertian, keuntungan, efeksamping, kontra
indikasi): ..............................................................................................................................................................................
.............................................................................................................................................................................................
.........................

Pengkajian Gangguan Sistem Reproduksi (GSR)

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Nama mahasiswa : …………………… Tanggal pengkajian :………………………

NIM : ………………………………………Ruangan/RS : ………………………………
I. Data umum klien
No. Reg : ......................................................................................................
Initial : ...........................................................................................................
Alamat : ......................................................................................................
Tgl masuk RS : .............................................................................................
Tgl pengkajian : ............................................................................................
Diagnosa medis : ..........................................................................................
II. Masalah utama
Keluhan utama : .............................................................................................
Riwayat keluhan utama
mulai timbulnya : ......................................................................................
sifat keluhan : ..........................................................................................
lokasi keluhan : ........................................................................................
faktor pencetus : .......................................................................................
keluhan lain : ...........................................................................................
pengaruh keluhan terhadap aktivitas/fungsi tubuh : .................................
usaha klien untuk mengatasinya : ...........................................................
III. Pengkajian Fisik
Seksualitas
Subyektif :
Usia menarche : ..........tahun
Siklus haid : .................hari
Durasi haid : ................hari
Dismenorea Polimenorea Oligomenorea
Menometroragie Amenorea
Rabas pervagina : warna : ............................................
Jumlah : .........................................
Berapa lama : ................................
Metode kontrasepsi terakhir : .......................................
Status obstetri : P : .......................A : ........................
Riwayat persalinan :
Term penuh :................. Prematur : ................
Multiple : .......................
Riwayat persalinan terakhir :
Tahun :.......................... tempat : ...................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Lama gestasi : .............. lama persalinan : ...............................

Jenis persalinan : .....................................................................
Berat badan bayi : ..............gr
Komplikasi maternal/bayi : .......................................................
Obyektif :
PAP smear terakhir (tgl dan hasil) : ........................................................
Tes serologi (tgl dan hasil) : ....................................................................
Makanan dan Cairan
Subyektif :
Masukan oral 4 jam terakhir : ..................................................................
Mual /muntah Hilang nafsu makan Masalah mengunyah Pola makan :
Frekuensi : ...........x/hari
Konsumsi cairan : ....................../hari

Obyektif :
BB : ................kg
TB : ................cm
Turgor kulit : .............................................................................................
Membran mukosa mulut : .............................................
Kebutuhan cairan : .....................................................................
Pemeriksaan Hb, Ht (Tgl dan hasil) : ........................................
Eliminasi
Subyektif :
Frekuensi Defekasi : ..................................................................
Penggunaan Laksatif : ..............................................................
Waktu Defekasi terakhir : ...........................................................
Frekuensi berkemih : .................................................................
Karakter urine : ..........................................................................
Nyeri/rasa terbakar/kesulitan berkemih : ..................................
Riwayat penyakit ginjal : ...........................................................
Penyakit kandung kemih : ........................................................
Penggunaan Diuretik : ...............................................................
Obyektif :
Pemasangan kateter : ..................................................................
Bising usus : ................................................................................
Karakter urine : ..........................................................................
Konsistensi feces : ....................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Warna Feces : ............................................................................

Haemoroid : ...............................................................................
Palpasi Kandung kemih (teraba/tidak teraba) : ..........................

Aktivitas/istirahat
Subyektif :
Pekerjaan : ............................................................................
Hobby : ...................................................................................
Tidur malam (jam) : .................................................................
Tidur siang (jam) : ........................................................................
Obyektif :
Status neurologis : ...................................................................................
GCS : .......................................................................................................
Pengkajian Neuromuskuler :
Muscle Stretch refleks (Bisep/trisep/brachioradialis/patela/axiles) : .........
Rentang pergerakan sendi (ROM) : ........................................................
Derajat kekuatan otot : ............................................................................
Kuku (warna) : ..........................................................................................
Tekstur : ..................................................................................................
Membran Mukosa : .................................................................................
Konjungtiva : ............................................................................................
Sklera : .....................................................................................................
Hygiene
Subyektif :
Kebersihan rambut (frekuensi) : ..............................................................
Kebersihan badan : ..................................................................................
Kebersihan gigi/mulut : .............................................................................
Kebersihan kuku tangan dan kaki : ..........................................................
Objektif :
Cara berpakaian : ....................................................................................
Kondisi kulit kepala : ...............................................................................
Sirkulasi
Subyektif
Riwayat penyakit jantung : ......................................................................
Riwayat demam reumatik : ......................................................................
Obyektif :
Tekanan darah : ............................................................................

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Nadi : ...........................................................................................
Distensi vena jugularis (ada/tidak ada) : .................................................
Bunyi jantung : .........................................................................................
Frekuensi : ..............................................................................................
Irama (teratur/tidak teratur) : ....................................................................
Kualitas (kuat/lemah/Rub/Murmur) : ........................................................
Ektremitas :
Suhu (hangat/akral dingin) : .....................................................................
CRT : ........................................................................................................
Varises (ada/tidak ada) : CRT : ................................................................
Nyeri/ketidaknyamanan
Subyektif :
Lokasi : ...........................................................................
Intensitas (skala 0-10): ...................................................
Frekuensi : .......................................................................
Durasi : ............................................................................
Faktor pencetus : .............................................................
Cara mengatasi : ......................................................................................
Faktor yang berhubungan : .....................................................................
Objektif :
Wajah meringis
Melindungi area yang sakit
Fokus menyempit
Pernafasan
Subyektif :
Dispnoe Batuk/sputum Riwayat Bronkhitis
Asma Tuberkulosis Emfisema
Pneumonia berulang Perokok, lamanya : ..........tahun
Penggunaan alat bantu pernafasan (O2) : ........L/menit

Obyektif :
Frekuensi : ...............x/menit
Irama : Eupnoe Tachipnoe Bradipnoe
Apnoe Hiperventilasi Cheynestokes
Kusmaul Biots
Bunyi nafas : Bronchovesikuler Vesikuler Bronchial
Karakteristik sputum :

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Hasil rontgen :
Interaksi sosial
Subyektif
Satus pernikahan : ..........................................................................
Lama pernikahan : ..........................................................................
Tinggal serumah dengan : ......................................................................
Obyektif
Komunikasi verbal/nonverbal dengan orang terdekat : ............................
Integritas ego
Subyektif
Perencanaan kehamilan : .......................................................................
Perasaan klien/keluarga tentang penyakit : ............................................
Status hubungan : ..........................................................................
Masalah keuangan : ..........................................................................
Cara mengatasi stres : ..........................................................................
Obyektif
Status emosional (cemas,apatis, dll) : ....................................................
Respon fisiologis yang teramati : ............................................................
Agama : ..........................................................................
Muncul perasaan (tidak berdaya, putus asa, tidak mampu) : ..................
Neurosensori
Subyektif
Pusing (ada/tidak ada): ..........................................................................
Kesemutan/kebas/kelembaban (lokasi) : .................................................
Keamanan
Subyektif :
Alergi/sensitivitas : ..........................................................................
Penyakit masa kanak-kanak : ................................................................
Riwayat imunisasi : ..........................................................................
Infeksi virus terakhir : ..........................................................................
Binatang peliharaan dirumah : ................................................................
Masalah obstetrik sebelumnya : ...............................................................
Jarak waktu kehamilan terakhir : ..............................................................
Riwayat kecelakaan : ..........................................................................
Fraktur dislokasi : ..........................................................................
Pembesaran kelenjar : ..........................................................................
Obyektif

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Integritas kulit : ..........................................................................

Cara berjalan : ..........................................................................
Penyuluhan/pembelajaran
Subyektif
Bahasa dominan : ..........................................................................
Pendidikan terakhir : ..........................................................................
Pekerjaan suami : ..........................................................................
Faktor penyakit dari keluarga : ................................................................
Sumber pendidikan tentang penyakit : ....................................................
Pertimbangan rencana pulang
Tanggal informasi diambil : ..........................................................................
Pertimbangan rencana pulang : .....................................................................
Tanggal perkiraan pulang : ..........................................................................
Ketersediaan sumber kesehatan terdekat : ....................................................

Pemeriksaan diagnostik :

Terapi dan pengobatan :

ANALISA DATA

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Nama Klien : Ruang Rawat:

Diagnosa Medis : No. Rekam Medis:

DATA MASALAH KEPERAWATAN

Data Subjektif (DS) :

Data Objektif (DO) :

Data Subjektif (DS):

Data Objektif (DO):

Data Subjektif (DS):

Data Objektif (DO):

Data Subjektif (DS) :

Data Objektif (DO) :

Bagan Penyimpangan KDM/ Patoflow

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

Diagnosa Keperawatan Prioritas

1.
2.
3.

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 STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

RENCANA KEPERAWATAN
Nama Pasien :____________________________________ Ruang Rawat:____________________
Diagnosa Medis : ___________________________________ No. Rekam Medis :______________
No. Tgl Diagnosa Keperawatan Tujuan Rencana Rasional
& Data Penunjang Tindakan

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 STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

No. Tgl Diagnosa Keperawatan Tujuan Rencana Rasional

& Data Penunjang Tindakan

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 STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

CATATAN PERKEMBANGAN

Nama Klien : Ruang rawat :

Diagnosa Medis : No. Rekam Medis :
Diagnosa Keperawatan:
Tgl/ Implementasi Paraf Evaluasi (S O A P) Paraf
Jam &Nama Tanggal/jam &Nama

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 STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

CATATAN PERKEMBANGAN

Nama Klien : Ruang rawat :

Diagnosa Medis : No. Rekam Medis :
Diagnosa Keperawatan:
Tgl/ Implementasi Paraf Evaluasi (S O A P) Paraf
Jam &Nama Tanggal/jam &Nama

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STIKes IMC Bintaro/ Format Asuhan Keperawatan Maternitas

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