PROGRAM STUDI NERS

SEKOLAH TINGGI ILMU KESEHATAN HUSADA JOMBANG

Jl. Veteran Mancar Peterongan Jombang 61481 Tel/Fax 0321-877025
Email : husadajombangstikes@yahoo.co.id Website : www.shj.ac.id

Nama Mahasiswa : __________________________

NIM : __________________________

Pengkajian Antenatal (Maternitas)

Tanggal Masuk : ..................................................Jam Masuk : .........................................

Ruang : ..................................................Kamar No : .........................................
Pengkajian Tanggal : ..................................................Jam : .........................................

A. Identitas
Nama Pasien : .............................................................Nama Suami : ........................................
Umur : .............................................................Umur : .........................................
Suku/ Bangsa : .............................................................Suku/bangsa : .........................................
Agama : .............................................................Agama : .........................................
Pendidikan : .............................................................Pendidikan : .........................................
Pekerjaan : .............................................................Pekerjaan : .........................................
Alamat : .............................................................Alamat : .........................................
............................................................. .........................................
Status Perkawinan : .............................................................

B. Riwayat Keperawatan
1. Riwayat Obstetri
A. Riwayat Menstruasi
Menarche : .............................................................Siklus : teratur ( ) tidak
( )
Banyaknya : .............................................................Lamanya : .........................................
HPHT : .............................................................Keluhan : .........................................

B. Riwayat Kehamilan, persalinan, nifas yang lalu

Anak
Kehamilan Persalinan Komplikasi Nifas Anak
Ke
Umur
N Tahu Penyuli Jeni Penolon Penyuli Laseras Infeks Perdaraha Jeni B P
Kehamila
o n t s g t i i n s B J
n

C. Genogram
D. Kehamilan Sekarang
Diagnosa : .............................................................
Imunisasi : TT 1 ( ) sudah, ( ) belum
TT 2 ( ) sudah, ( ) belum
ANC berapa kali : .............................................................
Keluhan selama hamil : ..............................................................................................................................
..................................................................................................................................
Pengobatan selama hamil : ( ) ya, ( ) tidak
Pergerakan janin : ( ) ya, ( ) tidak, sejak usia : ............................................................................
Rencana perawatan bayi : ( ) sendiri, ( ) orang tua, ( ) lain-lain
Breast Care : .............................................................
Perineal Care : .............................................................
Nutrisi : .............................................................
Senam Nifas : .............................................................
KB : .............................................................
Menyusui : .............................................................

2. Riwayat Keluarga Berencana

Melaksanakan KB : ( ) ya, ( ) tidak
Bila ya, jenis kontrasepsi apa yang digunakan : . ................................................................................
Sejak kapan menggunakan kontrasepsi :. .................................................................................
Masalah yang terjadi :. .................................................................................
...................................................................................
...................................................................................

3. Riwayat Kesehatan
Penyakit yang pernah dialami ibu
Pengobatan yang didapat
Riwayat penyakit keluarga
4. Riwayat Lingkungan
Kebersihan
Bahaya
Lainnya, sebutkan
:. .................................................................................
:. .................................................................................
:. .( ) diabetes melitus
...( ) jantung
...( ) hipertensi
...( ) lainnya, sebutkan :........................................
:. ..............................................................................................................................
:. ..............................................................................................................................
:. ..............................................................................................................................

5. Aspek Psikososial
Persepsi ibu setelah bersalin :. ...............................................................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?
Bila ya bagaimana :. ...............................................................................................................
Harapan yg ibu inginkan setelah bersalin : .............................................................................................
Ibu tinggal dengan siapa :. ...............................................................................................................
Siapa orang yang terpenting bagi ibu .....................................................................................................
Sikap anggota keluarga terhadap keadaan saat ini ...............................................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. Kebutuhan Dasar Khusus
a. Pola Nutrisi
Frekwensi makan :. ...............................................................................................................
Nafsu makan :( ) baik, ( ) tidak nafsu, alasan .................................................
Jenis makanan rumah :. ...............................................................................................................
Makanan yg tdk disukai/ alergi/ pantangan .........................................................................................
 b. Pola eliminasi
BAK
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Keluhan saat BAK :. ...............................................................................................................
BAB
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Bau :. ...............................................................................................................
Konsistensi :. ...............................................................................................................
Keluhan saat BAB :. ...............................................................................................................
c. Pola personal hygiene
Mandi
Frekwensi :. ..............................................................................................kali/ hari
Sabun :( ) ya, ( ) tidak
Oral Hygiene
Frekwensi :. ..............................................................................................kali/ hari
Waktu :( ) pagi, ( ) sore, ( ) setelah makan
Cuci rambut
Frekwensi :. ..............................................................................................kali/ hari
Shampo :( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : . .............................................................................................jam/ hari
Kebiasaan sebelum tidur :. ...............................................................................................................
Keluhan :. ...............................................................................................................
e. Pola aktivitas dan latihan
Kegiatan dalam pekerjaan :. ...............................................................................................................
Waktu bekerja :( ) pagi, ( ) sore, ( ) malam
Olah raga :( ) ya, ( ) tidak
Jenisnya :. ...............................................................................................................
Frekwensi :. ...............................................................................................................
Kegiatan waktu luang :. ...............................................................................................................
Keluhan dalam aktifitas :. ...............................................................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
Merokok :. ...............................................................................................................
Minuman keras :. ...............................................................................................................
Ketergantungan obat :. ...............................................................................................................
7. Pemeriksaan Fisik
Keadaan umum :. ...............................................................................................................
Tekanan darah :. ...............................................................................................................
Respirasi :. ...............................................................................................................
Berat badan :. ...........................................................................................................kg
Kesadaran :. ...............................................................................................................
Nadi :. ...........................................................................................kali/ menit
Suhu :. ...........................................................................................kali/ menit
Tinggi badan :. ..........................................................................................................cm

Kepala, mata, kuping, hidung dan tenggorokan

Kepala Bentuk :. ...............................................................................................................
Keluhan :. ...............................................................................................................
Mata Kelopak mata :. ...............................................................................................................
 Gerakan mata :. ...............................................................................................................
Konjungtiva :. ...............................................................................................................
Sklera : . ..............................................................................................................
Pupil :. ...............................................................................................................
Akomudasi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Hidung Reaksi alergi :. ...............................................................................................................
Sinus :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................

Mulut dan tenggorokan

Gigi geligi :. ...............................................................................................................
Kesulitan menelan :............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Dada dan Axilla
Mammae : membesar : ( ) ya, ( ) tidak
Areolla mammae :..............................................................................................................
Papilla mammae : ..............................................................................................................
Colostrum :. ...............................................................................................................
Pernafasan Jalan nafas :. ...............................................................................................................
Suara nafas :. ...............................................................................................................
Menggunakan otot bantu pernafasan : ...........................................................................
Lainnya, sebut :. ...............................................................................................................
Sirkulasi jantung
Kecepatan denyut acipal :. ...........................................................................................kali/ menit
Irama :. ...............................................................................................................
Kelinan bunyi jantung :. ...............................................................................................................
Sakit dada :. ...............................................................................................................
Timbul :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................
Abdomen Mengecil :. ...............................................................................................................
Linea & striae :. ...............................................................................................................
Luka bekas operasi : ..........................................................................................................
Leopold I :. ...............................................................................................................
Leopold II :. ...............................................................................................................
Leopold III :. ...............................................................................................................
Leopold IV :. ...............................................................................................................
Denyut jantung janin : ......................................................................................................:
Kontraksi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Genitourinary Keputihan :. ...............................................................................................................
Pap Smear :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Ekstremitas (integumen/ muskuloskeletal)
Turgor kulit :. ...............................................................................................................
Warna kulit :. ...............................................................................................................
Kontraktur pada persendian ekstremitas : ..............................................................................................
Kesulitan dalam pergerakan :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................

C. Data Penunjang
 1. Laboratorium :. ...............................................................................................................
2. USG :. ...............................................................................................................
3. Rontgen :. ...............................................................................................................
4. Terapi yang didapat :. ...............................................................................................................

D. Data Tambahan
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

____________, ________________
Pemeriksa,

(_______________________)
 PROGRAM STUDI NERS
SEKOLAH TINGGI ILMU KESEHATAN HUSADA JOMBANG
Jl. Veteran Mancar Peterongan Jombang 61481 Tel/Fax 0321-877025
Email : husadajombangstikes@yahoo.co.id Website : www.shj.ac.id

Nama Mahasiswa : __________________________

NIM : __________________________

Pengkajian Intranatal (Maternitas)

Tanggal Masuk : ..................................................Jam Masuk : .........................................

Ruang : ..................................................Kamar No : .........................................
Pengkajian Tanggal : ..................................................Jam : .........................................

A. Identitas
Nama Pasien : .............................................................Nama Suami : ........................................
Umur : .............................................................Umur : .........................................
Suku/ Bangsa : .............................................................Suku/bangsa : .........................................
Agama : .............................................................Agama : .........................................
Pendidikan : .............................................................Pendidikan : .........................................
Pekerjaan : .............................................................Pekerjaan : .........................................
Alamat : .............................................................Alamat : .........................................
............................................................. .........................................
Status Perkawinan : .............................................................

B. Riwayat Keperawatan
1. Riwayat Obstetri
A. Riwayat Menstruasi
Menarche : .............................................................Siklus : teratur ( ) tidak
( )
Banyaknya : .............................................................Lamanya : .........................................
HPHT : .............................................................Keluhan : .........................................

B. Riwayat Kehamilan, persalinan, nifas yang lalu

Anak
Kehamilan Persalinan Komplikasi Nifas Anak
Ke
Umur
N Tahu Penyuli Jeni Penolon Penyuli Laseras Infeks Perdaraha Jeni B P
Kehamila
o n t s g t i i n s B J
n
 C. Genogram

D. Persalinan Sekarang
1. Keluhan His
Mulai kontraksi tanggal/ jam ...........................................( ) teratur, ( ) tidak
Interval : .............................................................
Lama : .............................................................
Kekuatan : .............................................................
2. Pengeluaran pervagina
Jenis : ( ) lendir, ( ) darah, ( ) darah lendir, ( ) air ketuban
Jumlah : .............................................................
3. Periksa dalam
Jam : .............................................................
Oleh : .............................................................
Hasil : .............................................................
Effecement .........................................%
Ketuban : +/-
Presentasi anak .................................
Bidang Hodge ...................................
4. Kala Persalinan
a. Kala I
- Mulai persalinan : tgl ...................................................jam : ..........................................................
- Lama kala I : ………………………jam ………………………menit
- Pengobatan yang didapat : ...............................................................................................................
b. Kala II
- Mulai : tgl ........................................................jam :............................................................
- Lama kala II : .............................................................jam ...................................................menit
- Pengobatan yang didapat :...............................................................................................................
- Penyulit : ..................................................................................................................................
- Cara mengatasi :.................................................................................................................................
- Keadaan bayi : Lahir tgl .............................................jam : ...........................................................
Jenis kelamin : L/P
Apgar Score 1 : .................................
Apgar Score 5 : .................................
c. Kala III
- Mulai : tgl ........................................................jam : ...........................................................
 - TFU : .............................................................kontraksi uterus : ( ) baik, ( )
tidak
- Lama kala III : .............................................................jam ...................................................menit
- Cara kelahiran plasenta : ( ) spontan, ( ) tindakan
Sebutkan : ..................................................................................................................................
- Kotiledon : ( ) lengkap, ( ) tidak
- Selaput : ( ) lengkap, ( ) tidak
- Perdarahan selama persalinan :..................................cc
- Pengobatan yang didapat : ..............................................................................................................
d. Kala IV
- Keadaan umum : ...............................................................................................................................
- Tanda vital : TD : ......................................................mmHg P : ............................kali/menit
N : .......................................................x/mnt S : .........................................∘ C
- TFU : .............................................................
- Kontraksi uterus : ( ) baik, ( ) jelek
- Perdarahan : ( ) ya, ( ) tidak. Jumlah .............cc
- Perineum : ( ) ruptur spontan, ( ) episiotomi
5. Keadaan Bayi
a. BB : .............................................................gram
b. PB : .............................................................cm
c. Pusat : ( ) normal, ( ) abnormal
d. Perawatan tali pusat :
( ) alkohol 70%
( ) bethadine ( ) lainnya :...................................................
e. Anus : ( ) berlubang, ( ) tertutup
f. Suhu : ............................................................. ∘ C
g. Lingkar kepala : .............................................................
Lingkar Sub Occipito Bregnatica : ................................cm
Lingkar Fronto Occipitalis : ...........................................cm
Lingkar Mento Occipitalis : ..........................................cm
h. Kelainan kepala :
( ) caput succedanum ( ) cephal hematoma
( ) hidocephalus ( ) microcephalus
( ) an encephalus
Lain – lain : ..................................................................................................................................
Pengobatan yang didapat :.........................................................................................................................

E. Rencana Perawatan Bayi : ( ) sendiri, ( ) orang tua, ( ) lain – lain

Kesanggupan dan pengetahuan dalam merawat bayi :
Breast Care : .............................................................
Perineal Care : .............................................................
Nutrisi : .............................................................
Senam Nifas : .............................................................
KB : .............................................................
Menyusui : .............................................................

2. Riwayat Keluarga Berencana

Melaksanakan KB : ( ) ya, ( ) tidak
Bila ya, jenis kontrasepsi apa yang digunakan : . ................................................................................
Sejak kapan menggunakan kontrasepsi :. .................................................................................
Masalah yang terjadi :. .................................................................................
...................................................................................
...................................................................................
3. Riwayat Kesehatan
Penyakit yang pernah dialami ibu :. .................................................................................
Pengobatan yang didapat :. .................................................................................
Riwayat penyakit keluarga :. .( ) diabetes melitus
...( ) jantung
...( ) hipertensi
...( ) lainnya, sebutkan :........................................
4. Riwayat Lingkungan
Kebersihan :. ..............................................................................................................................
Bahaya :. ..............................................................................................................................
Lainnya, sebutkan :. ..............................................................................................................................
5. Aspek Psikososial
Persepsi ibu setelah bersalin :. ...............................................................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?
Bila ya bagaimana :. ...............................................................................................................
Harapan yg ibu inginkan setelah bersalin : .............................................................................................
Ibu tinggal dengan siapa :. ...............................................................................................................
Siapa orang yang terpenting bagi ibu .....................................................................................................
Sikap anggota keluarga terhadap keadaan saat ini ...............................................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. Kebutuhan Dasar Khusus
a. Pola Nutrisi
Frekwensi makan :. ...............................................................................................................
Nafsu makan :( ) baik, ( ) tidak nafsu, alasan .................................................
Jenis makanan rumah :. ...............................................................................................................
Makanan yg tdk disukai/ alergi/ pantangan .........................................................................................
b. Pola eliminasi
BAK
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Keluhan saat BAK :. ...............................................................................................................
BAB
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Bau :. ...............................................................................................................
Konsistensi :. ...............................................................................................................
Keluhan saat BAB :. ...............................................................................................................
c. Pola personal hygiene
Mandi
Frekwensi :. ..............................................................................................kali/ hari
Sabun :( ) ya, ( ) tidak
Oral Hygiene
Frekwensi :. ..............................................................................................kali/ hari
Waktu :( ) pagi, ( ) sore, ( ) setelah makan
Cuci rambut
Frekwensi :. ..............................................................................................kali/ hari
Shampo :( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : . .............................................................................................jam/ hari
Kebiasaan sebelum tidur :. ...............................................................................................................
 Keluhan :. ...............................................................................................................
e. Pola aktivitas dan latihan
Kegiatan dalam pekerjaan :. ...............................................................................................................
Waktu bekerja :( ) pagi, ( ) sore, ( ) malam
Olah raga :( ) ya, ( ) tidak
Jenisnya :. ...............................................................................................................
Frekwensi :. ...............................................................................................................
Kegiatan waktu luang :. ...............................................................................................................
Keluhan dalam aktifitas :. ...............................................................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
Merokok :. ...............................................................................................................
Minuman keras :. ...............................................................................................................
Ketergantungan obat :. ...............................................................................................................
7. Pemeriksaan Fisik
Keadaan umum :. ...............................................................................................................
Tekanan darah :. ...............................................................................................................
Respirasi :. ...............................................................................................................
Berat badan :. ...........................................................................................................kg
Kesadaran :. ...............................................................................................................
Nadi :. ...........................................................................................kali/ menit
Suhu :. ...........................................................................................kali/ menit
Tinggi badan :. ..........................................................................................................cm

Kepala, mata, kuping, hidung dan tenggorokan

Kepala Bentuk :. ...............................................................................................................
Keluhan :. ...............................................................................................................
Mata Kelopak mata :. ...............................................................................................................
Gerakan mata :. ...............................................................................................................
Konjungtiva :. ...............................................................................................................
Sklera : . ..............................................................................................................
Pupil :. ...............................................................................................................
Akomudasi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Hidung Reaksi alergi :. ...............................................................................................................
Sinus :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Mulut dan tenggorokan
Gigi geligi :. ...............................................................................................................
Kesulitan menelan :............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Dada dan Axilla
Mammae : membesar : ( ) ya, ( ) tidak
Areolla mammae :..............................................................................................................
Papilla mammae : ..............................................................................................................
Colostrum :. ...............................................................................................................
Pernafasan Jalan nafas :. ...............................................................................................................
Suara nafas :. ...............................................................................................................
Menggunakan otot bantu pernafasan : ...........................................................................
Lainnya, sebut :. ...............................................................................................................
Sirkulasi jantung
Kecepatan denyut acipal :. ...........................................................................................kali/ menit
 Irama :. ...............................................................................................................
Kelinan bunyi jantung :. ...............................................................................................................
Sakit dada :. ...............................................................................................................
Timbul :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................
Abdomen Mengecil :. ...............................................................................................................
Linea & striae :. ...............................................................................................................
Luka bekas operasi : ..........................................................................................................
TFU :. ...............................................................................................................
Kontraksi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Genitourinary Perineum :. ...............................................................................................................
Lokhea :. ...............................................................................................................
Vesika urinaria :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Ekstremitas (integumen/ muskuloskeletal)
Turgor kulit :. ...............................................................................................................
Warna kulit :. ...............................................................................................................
Kontraktur pada persendian ekstremitas : ..............................................................................................
Kesulitan dalam pergerakan :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................

C. Data Penunjang
1. Laboratorium :. ...............................................................................................................
2. USG :. ...............................................................................................................
3. Rontgen :. ...............................................................................................................
4. Terapi yang didapat :. ...............................................................................................................

D. Data Tambahan
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

____________, ________________
Pemeriksa,

(_______________________)

PROGRAM STUDI NERS

SEKOLAH TINGGI ILMU KESEHATAN HUSADA JOMBANG
 Jl. Veteran Mancar Peterongan Jombang 61481 Tel/Fax 0321-877025
Email : husadajombangstikes@yahoo.co.id Website : www.shj.ac.id

Nama Mahasiswa : __________________________

NIM : __________________________

Pengkajian Post Partum (Maternitas)

Tanggal Masuk : ..................................................Jam Masuk : .........................................

Ruang : ..................................................Kamar No : .........................................
Pengkajian Tanggal : ..................................................Jam : .........................................

A. Identitas
Nama Pasien : .............................................................Nama Suami : ........................................
Umur : .............................................................Umur : .........................................
Suku/ Bangsa : .............................................................Suku/bangsa : .........................................
Agama : .............................................................Agama : .........................................
Pendidikan : .............................................................Pendidikan : .........................................
Pekerjaan : .............................................................Pekerjaan : .........................................
Alamat : .............................................................Alamat : .........................................
............................................................. .........................................
Status Perkawinan : .............................................................

B. Riwayat Keperawatan
1. Riwayat Obstetri
A. Riwayat Menstruasi
Menarche : .............................................................Siklus : teratur ( ) tidak
( )
Banyaknya : .............................................................Lamanya : .........................................
HPHT : .............................................................Keluhan : .........................................

B. Riwayat Kehamilan, persalinan, nifas yang lalu

Anak
Kehamilan Persalinan Komplikasi Nifas Anak
Ke
Umur
N Tahu Penyuli Jeni Penolon Penyuli Laseras Infeks Perdaraha Jeni B P
Kehamila
o n t s g t i i n s B J
n

C. Genogram
D. Post Partum Sekarang :
Riwayat persalinan sekarang :..............................................
Tipe persalinan : spontan/ bantuan ............................
 Lama persalinan :
Kala I : .............................................................jam
Kala II : .............................................................jam
Kala III : .............................................................jam
Kala IV : .............................................................jam

E. Rencana perawatan bayi : ( ) sendiri, ( ) orang tua, ( ) lain-lain

Kesanggupan dan pengetahuan dalam merawat bayi
Breast care : ..................................................................................................................................
Perineal care : ..................................................................................................................................
Nutrisi : ..................................................................................................................................
Senam Nifas : ..................................................................................................................................
KB : ..................................................................................................................................
Menyusui : ..................................................................................................................................

2. Riwayat Keluarga Berencana

Melaksanakan KB : ( ) ya, ( ) tidak
Bila ya, jenis kontrasepsi apa yang digunakan : . ................................................................................
Sejak kapan menggunakan kontrasepsi :. .................................................................................
Masalah yang terjadi :. .................................................................................
...................................................................................
...................................................................................

3. Riwayat Kesehatan
Penyakit yang pernah dialami ibu :. .................................................................................
Pengobatan yang didapat :. .................................................................................
Riwayat penyakit keluarga :. .( ) diabetes melitus
...( ) jantung
...( ) hipertensi
...( ) lainnya, sebutkan :........................................

4. Riwayat Lingkungan
Kebersihan :. ..............................................................................................................................
Bahaya :. ..............................................................................................................................
Lainnya, sebutkan :. ..............................................................................................................................

5. Aspek Psikososial
Persepsi ibu setelah bersalin :. ...............................................................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?
Bila ya bagaimana :. ...............................................................................................................
Harapan yg ibu inginkan setelah bersalin : .............................................................................................
Ibu tinggal dengan siapa :. ...............................................................................................................
Siapa orang yang terpenting bagi ibu .....................................................................................................
Sikap anggota keluarga terhadap keadaan saat ini ...............................................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

6. Kebutuhan Dasar Khusus

a. Pola Nutrisi
Frekwensi makan :. ...............................................................................................................
Nafsu makan :( ) baik, ( ) tidak nafsu, alasan .................................................
Jenis makanan rumah :. ...............................................................................................................
Makanan yg tdk disukai/ alergi/ pantangan .........................................................................................
 b. Pola eliminasi
BAK
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Keluhan saat BAK :. ...............................................................................................................
BAB
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Bau :. ...............................................................................................................
Konsistensi :. ...............................................................................................................
Keluhan saat BAB :. ...............................................................................................................
c. Pola personal hygiene
Mandi
Frekwensi :. ..............................................................................................kali/ hari
Sabun :( ) ya, ( ) tidak
Oral Hygiene
Frekwensi :. ..............................................................................................kali/ hari
Waktu :( ) pagi, ( ) sore, ( ) setelah makan
Cuci rambut
Frekwensi :. ..............................................................................................kali/ hari
Shampo :( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : . .............................................................................................jam/ hari
Kebiasaan sebelum tidur :. ...............................................................................................................
Keluhan :. ...............................................................................................................
e. Pola aktivitas dan latihan
Kegiatan dalam pekerjaan :. ...............................................................................................................
Waktu bekerja :( ) pagi, ( ) sore, ( ) malam
Olah raga :( ) ya, ( ) tidak
Jenisnya :. ...............................................................................................................
Frekwensi :. ...............................................................................................................
Kegiatan waktu luang :. ...............................................................................................................
Keluhan dalam aktifitas :. ...............................................................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
Merokok :. ...............................................................................................................
Minuman keras :. ...............................................................................................................
Ketergantungan obat :. ...............................................................................................................

7. Pemeriksaan Fisik
Keadaan umum :. ...............................................................................................................
Tekanan darah :. ...............................................................................................................
Respirasi :. ...............................................................................................................
Berat badan :. ...........................................................................................................kg
Kesadaran :. ...............................................................................................................
Nadi :. ...........................................................................................kali/ menit
Suhu :. ...........................................................................................kali/ menit
Tinggi badan :. ..........................................................................................................cm

Kepala, mata, kuping, hidung dan tenggorokan

Kepala Bentuk :. ...............................................................................................................
Keluhan :. ...............................................................................................................
 Mata Kelopak mata :. ...............................................................................................................
Gerakan mata :. ...............................................................................................................
Konjungtiva :. ...............................................................................................................
Sklera : . ..............................................................................................................
Pupil :. ...............................................................................................................
Akomudasi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Hidung Reaksi alergi :. ...............................................................................................................
Sinus :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Mulut dan tenggorokan
Gigi geligi :. ...............................................................................................................
Kesulitan menelan :............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Dada dan Axilla
Mammae : membesar : ( ) ya, ( ) tidak
Areolla mammae :..............................................................................................................
Papilla mammae : ..............................................................................................................
Colostrum :. ...............................................................................................................
Pernafasan Jalan nafas :. ...............................................................................................................
Suara nafas :. ...............................................................................................................
Menggunakan otot bantu pernafasan : ...........................................................................
Lainnya, sebut :. ...............................................................................................................
Sirkulasi jantung
Kecepatan denyut acipal :. ...........................................................................................kali/ menit
Irama :. ...............................................................................................................
Kelinan bunyi jantung :. ...............................................................................................................
Sakit dada :. ...............................................................................................................
Timbul :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................
Abdomen Mengecil :. ...............................................................................................................
Linea & striae :. ...............................................................................................................
Luka bekas operasi : ..........................................................................................................
TFU :. ...............................................................................................................
Kontraksi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Genitourinary Perineum :. ...............................................................................................................
Lokhea :. ...............................................................................................................
Vesika urinaria :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Ekstremitas (integumen/ muskuloskeletal)
Turgor kulit :. ...............................................................................................................
Warna kulit :. ...............................................................................................................
Kontraktur pada persendian ekstremitas : ..............................................................................................
Kesulitan dalam pergerakan :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................

C. Data Penunjang
1. Laboratorium :. ...............................................................................................................
2. USG :. ...............................................................................................................
3. Rontgen :. ...............................................................................................................
4. Terapi yang didapat :. ...............................................................................................................
D. Data Tambahan
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

____________, ________________
Pemeriksa,

(_______________________)
 PROGRAM STUDI NERS
SEKOLAH TINGGI ILMU KESEHATAN HUSADA JOMBANG
Jl. Veteran Mancar Peterongan Jombang 61481 Tel/Fax 0321-877025
Email : husadajombangstikes@yahoo.co.id Website : www.shj.ac.id

Nama Mahasiswa : __________________________

NIM : __________________________

Pengkajian Gangguan Sistem Reproduksi

(Maternitas)

Tanggal Masuk : ..................................................Jam Masuk : .........................................

Ruang : ..................................................Kamar No : .........................................
Pengkajian Tanggal : ..................................................Jam : .........................................

A. Identitas
Nama Pasien : .............................................................Nama Suami : ........................................
Umur : .............................................................Umur : .........................................
Suku/ Bangsa : .............................................................Suku/bangsa : .........................................
Agama : .............................................................Agama : .........................................
Pendidikan : .............................................................Pendidikan : .........................................
Pekerjaan : .............................................................Pekerjaan : .........................................
Alamat : .............................................................Alamat : .........................................
............................................................. .........................................
Status Perkawinan : .............................................................

B. Status Kesehatan Saat Ini

1. Alasan kunjungan ke rumah sakit :
.........................................................................................................................................................................
.........................................................................................................................................................................
2. Keluhan utama saat ini :
.........................................................................................................................................................................
.........................................................................................................................................................................
3. Timbulnya keluhan : ( ) bertahap, ( ) mendadak
4. Faktor yang memperberat :
.........................................................................................................................................................................
.........................................................................................................................................................................
5. Upaya yang dilakukan untuk mengatasi :
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Diagnosa medik :
.........................................................................................................................................................................
.........................................................................................................................................................................

C. Riwayat Keperawatan
1. Riwayat Obstetri
A. Riwayat Menstruasi
Menarche : .............................................................Siklus : teratur ( ) tidak
( )
Banyaknya : .............................................................Lamanya : .........................................
HPHT : .............................................................Keluhan : .........................................
 B. Riwayat Kehamilan, persalinan, nifas yang lalu

Anak
Kehamilan Persalinan Komplikasi Nifas Anak
Ke
Umur
N Tahu Penyuli Jeni Penolon Penyuli Laseras Infeks Perdaraha Jeni B P
Kehamila
o n t s g t i i n s B J
n

C. Genogram

2. Riwayat Keluarga Berencana

Melaksanakan KB : ( ) ya, ( ) tidak
Bila ya, jenis kontrasepsi apa yang digunakan : . ................................................................................
Sejak kapan menggunakan kontrasepsi :. .................................................................................
Masalah yang terjadi :. .................................................................................
...................................................................................
...................................................................................

3. Riwayat Kesehatan
Penyakit yang pernah dialami ibu :. .................................................................................
Pengobatan yang didapat :. .................................................................................
Riwayat penyakit keluarga :. .( ) diabetes melitus
...( ) jantung
...( ) hipertensi
...( ) lainnya, sebutkan :........................................

4. Riwayat Lingkungan
Kebersihan :. ..............................................................................................................................
Bahaya :. ..............................................................................................................................
Lainnya, sebutkan :. ..............................................................................................................................

5. Aspek Psikososial
Persepsi ibu setelah bersalin :. ...............................................................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?
Bila ya bagaimana :. ...............................................................................................................
Harapan yg ibu inginkan setelah bersalin : .............................................................................................
Ibu tinggal dengan siapa :. ...............................................................................................................
Siapa orang yang terpenting bagi ibu .....................................................................................................
Sikap anggota keluarga terhadap keadaan saat ini ...............................................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. Kebutuhan Dasar Khusus
a. Pola Nutrisi
Frekwensi makan :. ...............................................................................................................
Nafsu makan :( ) baik, ( ) tidak nafsu, alasan .................................................
Jenis makanan rumah :. ...............................................................................................................
Makanan yg tdk disukai/ alergi/ pantangan .........................................................................................
b. Pola eliminasi
BAK
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Keluhan saat BAK :. ...............................................................................................................
BAB
Frekwensi :. .........................................................................................................kali
Warna :. ...............................................................................................................
Bau :. ...............................................................................................................
Konsistensi :. ...............................................................................................................
Keluhan saat BAB :. ...............................................................................................................
c. Pola personal hygiene
Mandi
Frekwensi :. ..............................................................................................kali/ hari
Sabun :( ) ya, ( ) tidak
Oral Hygiene
Frekwensi :. ..............................................................................................kali/ hari
Waktu :( ) pagi, ( ) sore, ( ) setelah makan
Cuci rambut
Frekwensi :. ..............................................................................................kali/ hari
Shampo :( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : . .............................................................................................jam/ hari
Kebiasaan sebelum tidur :. ...............................................................................................................
Keluhan :. ...............................................................................................................
e. Pola aktivitas dan latihan
Kegiatan dalam pekerjaan :. ...............................................................................................................
Waktu bekerja :( ) pagi, ( ) sore, ( ) malam
Olah raga :( ) ya, ( ) tidak
Jenisnya :. ...............................................................................................................
Frekwensi :. ...............................................................................................................
Kegiatan waktu luang :. ...............................................................................................................
Keluhan dalam aktifitas :. ...............................................................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
Merokok :. ...............................................................................................................
Minuman keras :. ...............................................................................................................
Ketergantungan obat :. ...............................................................................................................
7. Pemeriksaan Fisik
Keadaan umum :. ...............................................................................................................
Tekanan darah :. ...............................................................................................................
Respirasi :. ...............................................................................................................
Berat badan :. ...........................................................................................................kg
Kesadaran :. ...............................................................................................................
Nadi :. ...........................................................................................kali/ menit
Suhu :. ...........................................................................................kali/ menit
Tinggi badan :. ..........................................................................................................cm

Kepala, mata, kuping, hidung dan tenggorokan

Kepala Bentuk :. ...............................................................................................................
Keluhan :. ...............................................................................................................
Mata Kelopak mata :. ...............................................................................................................
Gerakan mata :. ...............................................................................................................
Konjungtiva :. ...............................................................................................................
Sklera : . ..............................................................................................................
Pupil :. ...............................................................................................................
Akomudasi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Hidung Reaksi alergi :. ...............................................................................................................
Sinus :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Mulut dan tenggorokan
Gigi geligi :. ...............................................................................................................
Kesulitan menelan :............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Dada dan Axilla
Mammae : membesar : ( ) ya, ( ) tidak
Areolla mammae :..............................................................................................................
Papilla mammae : ..............................................................................................................
Colostrum :. ...............................................................................................................
Pernafasan Jalan nafas :. ...............................................................................................................
Suara nafas :. ...............................................................................................................
Menggunakan otot bantu pernafasan : ...........................................................................
Lainnya, sebut :. ...............................................................................................................
Sirkulasi jantung
Kecepatan denyut acipal :. ...........................................................................................kali/ menit
Irama :. ...............................................................................................................
Kelinan bunyi jantung :. ...............................................................................................................
Sakit dada :. ...............................................................................................................
Timbul :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................
Abdomen Mengecil :. ...............................................................................................................
Linea & striae :. ...............................................................................................................
Luka bekas operasi : ..........................................................................................................
TFU :. ...............................................................................................................
Kontraksi :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Genitourinary Perineum :. ...............................................................................................................
Lokhea :. ...............................................................................................................
Vesika urinaria :. ...............................................................................................................
Lainnya, sebut :. ...............................................................................................................
Ekstremitas (integumen/ muskuloskeletal)
Turgor kulit :. ...............................................................................................................
Warna kulit :. ...............................................................................................................
Kontraktur pada persendian ekstremitas : ..............................................................................................
Kesulitan dalam pergerakan :. ...............................................................................................................
Lainnya, sebutkan :. ...............................................................................................................
C. Data Penunjang
1. Laboratorium :. ...............................................................................................................
2. USG :. ...............................................................................................................
3. Rontgen :. ...............................................................................................................
4. Terapi yang didapat :. ...............................................................................................................

D. Data Tambahan
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

____________, ________________
Pemeriksa,

(_______________________)