format asuhan keperawatan maternitas.doc

FORMAT ASUHAN KEPERAWATAN MATERNITAS

”PERIODE PRENATAL”

ASUHAN KEPERAWATAN PADA Ny..............................

DENGAN......................................................................................

DI POLI............................................

RS...............................................................

TANGGAL.....................................

A. PENGKAJIAN

I. IDENTITAS PASIEN PENANGGUNG/ SUAMINama : ………………………… Nama : ............... Umur : ………...…...………….. Umur : ................ Pendidikan : ........................................ Pendidikan : ...............Pekerjaan : ........................................ Pekerjaan : ...............Status perkawinan : ........................... Alamat : ...............Agama : .......................................Suku : .......................................Alamat : .......................................No. CM : ........................................Tanggal MRS : .......................................Tanggal pengkajian : .......................................Sumber informasi : .......................................

II. ALASAN KUNJUNGANKeluhan Utama/ alasan ke poli ...........................................................................................................................................................................................................................................................................................................................................

III. RIWAYAT OBSTETRI DAN GINEKOLOGIA. Riwayat Menstruasi :

Menarche : umur .......... Siklus : teratur ( ) tidak ( ) Banyaknya : ................... Lamanya: ............................. Keluhan : ................... HPHT : ...................

B. Riwayat pernikahan : Menikah: .......... kali Lama : .......... tahun

C. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

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

kelamin BB Pj

D. Riwayat Kehamilan Saat ini:Status Obstetrikus :

G....P....A........ UK : .............minggu TP : ............. ANC kehamilan ini: ................................ (Tuliskan riwayat ANC nya)

E. Riwayat Keluarga Berencana : Akseptor KB : jenis ............. Lama : ............. Masalah : ......................

(tuliskan riwayat penggunaan kontrasepsi)

F. Riwayat Penyakit Klien dan Keluarga………………………………………………………………………………….

IV. POLA FUNGSIONAL KESEHATAN1. Pemeliharaan dan persepsi terhadap kesehatan

....................................................................................................................2. Nutrisi/ metabolic

....................................................................................................................3. Pola eliminasi

.....................................................................................................................4. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4Makan/minumMandiToiletingBerpakaianMobilisasi di tempat tidurBerpindahAmbulasi ROM

0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total.

5. Oksigenasi: ....................................................................................................................

6. Pola tidur dan istirahat.....................................................................................................................

7. Pola perseptual....................................................................................................................

8. Pola persepsi diri ....................................................................................................................

9. Pola seksual dan reproduksi.....................................................................................................................

10.Pola peran-hubungan.....................................................................................................................

11.Pola manajemen koping stress.....................................................................................................................

12.Sistem nilai dan keyakinan.....................................................................................................................

V. PEMERIKSAAN FISIKKeadaan umum: GCS : ................................................ Tingkat kesadaran : ................................................ Tanda-tanda vital : TD.................. N.......... RR.......... T.......... BB : ....................... TB : .......... LILA :........

Head to toe:Kepala Wajah : Inspeksi : ...................................................... Palpasi : ......................................................

Mata: Inspeksi : ...................................................... Palpasi : ......................................................

Leher : Inspeksi : ...................................................... Palpasi : ......................................................

Dada:. Payudara Inspeksi :

Areola............. Puting : (menonjol/tidak)Tanda dimpling/ retraksi : ...........................

Palpasi : Pengeluaran ASI...........................Adanya nodul: ………………Perkusi : .....................................................

Jantung Inspeksi: .....................................................Palpasi : .....................................................Perkusi : .....................................................Auskultasi:.....................................................

Paru Inspeksi: .....................................................Palpasi : .....................................................Perkusi : .....................................................Auskultasi:.....................................................

Abdomen : Inspeksi : Linea : ................ Striae : .................

Pembesaran sesuai UK : .................. Gerakan janin : ...................... Kontraksi: ...............Luka bekas operasi : ..........................

Auskultasi : DJJ : .................. Bising Usus : .......................

Palpasi : Ballotement : ....................Leopold I : ……………… TFU : ...............Leopold II : Kanan : …………………….

Kiri : …………………….Leopold III : …………………………..Leopold IV : ………………………….. Penurunan kepala : ............ (penurunan bag. Terbawah dng metode lima jari)Kontraksi : .................

Perkusi : ..................

Genetalia dan perineum: Kebersihan : .................................................... Keputihan : .................................... Karakteristik: ..................... VT : ………………………(jika ada)

Anus: Hemoroid : ....................................................

Ektremitas: - Atas :

Oedema : ........................Varises : ........................CRT : ........................Kekuatan Otot : ........................Tonus : ........................

- Bawah :Oedema : .......................Varises : .......................CRT : .......................Refleks : .......................Kekuatan Otot : ........................Tonus : ........................

VI. DATA PENUNJANG Pemeriksaan Laboratorium : .......................... Pemeriksaan USG : ..........................

VII. Diagnosa medisVIII. Pengobatan

B. ANALISA DATA

DATA ETIOLOGI MASALAHDO: DS:

Diagnosa keperawatan berdasarkan prioritas:

1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATAN

NO DIAGNOSA RENCANA KEPERAWATANTUJUAN INTERVENSI RASIONAL

D. IMPLEMENTASI

TANGGAL/JAM

NO DX

IMPLEMENTASI EVALUASI/ RESPON KLIEN

PARAF/ NAMA

E. EVALUASI/ CATATAN PERKEMBANGAN

TGL/ JAM

NODIAGNOSA

EVALUASI

S :O :A :P :

Denpasar, ............................ 201…

Mengetahui,Preceptor klinik/ CI Mahasiswa

(........................................) (............................................)NIP. NIM.

Preceptor Akademik/ CT

(...............................................) NIP.


”PERIODE INTRANATAL”


DENGAN......................................................................................

DI RUANG............................................

RS...............................................................

TANGGAL........................................

1.A. PENGKAJIAN KALA II. IDENTITAS PASIEN PENANGGUNG/ SUAMINama : ………………………… Nama : ............... Umur : ………...…...………….. Umur : ...............Pendidikan : ........................................ Pendidikan : ...............Pekerjaan : ........................................ Pekerjaan : ...............Status perkawinan : .......................... Alamat : ...............Agama : .......................................Suku : .......................................Alamat : .......................................No. CM : ........................................Tanggal MRS : .......................................Tanggal pengkajian : .......................................Sumber informasi : .......................................

II. ALASAN DIRAWATKeluhan Utama (saat MRS dan sekarang)..................................................................................................................................Riwayat Kehamilan Sekarang ..................................................................................................................................






No TahunUmur

kehamilan

Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan

Jenis kelam

inBB Pj

D.Riwayat Kehamilan Saat ini:Status Obstetrikus :

G....P....A....H.... UK : .............minggu TP : ............. ANC kehamilan sekarang : .............. (tuliskan riwayat ANC pd kehamilan sekarang)

E. Riwayat Keluarga Berencana :

Akseptor KB : jenis ............. Lama : ............. Masalah : ......................

F. Riwayat Penyakit Klien dan Keluarga……………………………………………………………………………….

IV. POLA FUNGSIONAL KESEHATAN13.Pemeliharaan dan persepsi terhadap kesehatan

.....................................................................................................................14.Nutrisi/ metabolic

.....................................................................................................................15.Pola eliminasi

...................................................................................................................16.Pola aktivitas dan latihan



17.Oksigenasi: .................................................................................................................18. Pola tidur dan istirahat .................................................................................................................19.Pola perceptual ................................................................................................................20. Pola persepsi diri ................................................................................................................21. Pola seksual dan reproduksi .....................................................................................................................22. Pola peran-hubungan .....................................................................................................................23. Pola manajemen koping stress ....................................................................................................................24. Sistem nilai dan keyakinan ....................................................................................................................

V. PEMERIKSAAN FISIKKeadaan umum GCS : ................................................ Tingkat kesadaran : ................................................ Tanda-tanda vital : TD.................. N.......... RR.......... T.......... BB : ....................... TB : .......... LILA : ..........

Head to toeKepala Wajah : Inspeksi : ...................................................... Palpasi : ......................................................



Dada: Payudara Inspeksi :



Jantung Inspeksi: .....................................................Palpasi : .....................................................

Perkusi : .....................................................Auskultasi:.....................................................


Abdomen : Inspeksi : Linea : ............ Striae : ............. Luka bekas operasi: …………

Kontraksi : ………….Pembesaran sesuai UK : .................. Gerakan janin : .................

Auskultasi : DJJ : .................. Palpasi :

Leopold I : ……………………. TFU : ...............Leopold II : Kanan : …………………………………

Kiri : …………………………………Leopold III : ………………………………………….. Leopold IV : …………………………………………..Penurunan kepala : ............ (penurunan bag. Terbawah dng metode lima jari)Kontraksi : .................X/ 10 menit Durasi : …………………

Perkusi : ...........................

Genetalia dan perineum: Kebersihan : .................................................... Bloody show : .................................................... VT : ....................................................

Anus: Hemoroid : ....................................................


Oedema : ........................Varises : ........................CRT : ........................Kekuatan Otot : ........................Tonus : ........................

- Bawah :Oedema : .......................Varises : .......................CRT : .......................Refleks : ………………Kekuatan Otot : ........................Tonus : ........................

VI. DATA PENUNJANG Pemeriksaan Laboratorium : ......................... Pemeriksaan USG : ......................... DLL : ......................... Lampirkan Partograf

VII. DIAGNOSA MEDISVIII. PENGOBATAN

B. ANALISA DATA KALA I

DATA ETIOLOGI MASALAHDO:

DS:


1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATAN KALA I


D. IMPLEMENTASI KALA ITANGGAL

/JAMNO DX


PARAF/ NAMA

E. EVALUASI/ CATATAN PERKEMBANGAN KALA I

TGL./ JAM

NO.DIAGNOS

A

EVALUASI

S :O :A :P :

2. PENGKAJIAN KALA II

A. PENGKAJIAN DATA FOKUS…………………………………………………………………………………………………..

B. ANALISA DATA KALA II


DS:


1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATAN KALA II


D. IMPLEMENTASI KALA IITANGGAL

/JAMNO DX


PARAF/ NAMA

E. EVALUASI/ CATATAN PERKEMBANGAN KALA II

TGL./ JAM

NO.DIAGNOS

A

EVALUASI

S :O :A :P :

3. PENGKAJIAN KALA III

A. PENGKAJIAN DATA FOKUS………………………………………………………………………………..

B. ANALISA DATA KALA III


DS:


1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATAN KALA III


D. IMPLEMENTASI KALA IIITANGGAL

/JAMNO DX


PARAF/ NAMA

E. EVALUASI/ CATATAN PERKEMBANGAN KALA III

TGL./ JAM

NO.DIAGNOS

A

EVALUASI

S :O :A :P :

4. PENGKAJIAN KALA IV

A. PENGKAJIAN DATA FOKUS…………………………………………………………………………………..

B. ANALISA DATA KALA IV



1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATAN KALA IV

NO DIAGNOSA RENCANA KEPERAWATANTUJUAN INTERVENSI RASION

AL

D. IMPLEMENTASI KALA IVTANGGAL

/JAMNO DX


PARAF/ NAMA

E. EVALUASI/ CATATAN PERKEMBANGAN KALA IV

TGL./ JAM

NO.DIAGNOS

A

EVALUASI

S :O :A :P :

Denpasar, ............................ 201..

Mengetahui,Pembimbing klinik/ CI Mahasiswa(........................................) (...........................................)NIP. NIM.

Clinical Teacher/ CT

(...............................................)NIP.


”BAYI BARU LAHIR”

ASUHAN KEPERAWATAN PADA By .........................................

DENGAN ....................................................................................................

DI RUANG ............................................

RS ........................................

TANGGAL ............................................

A. PENGKAJIANI. IDENTITAS PASIENNama : ..........................................Umur : ..........................................Jenis kelamin : ..........................................Nama orang tua : ..........................................Tanggal MRS : ..........................................Tanggal pengkajian : ..........................................Sumber Informasi : ..........................................No. CM : ..........................................

II. RIWAYAT KELAHIRAN YANG LALUNo Tahun kelahiran Sex BB Lahir Keadaan

bayi Komplikasi Jenis persalinan Ket

III. RIWAYAT PERSALINANBB/ TB ibu : .........kg/ ...........cm Persalinan di .........................Keadaan umum ibu .......................................... Tanda vital ..........................Jenis persalinan ............................................... Proses persalinan ......................Kala I .......................jamIndikasi ................................. Kala II ...........menitKomplikasi persalinan: Ibu ............................. Janin ........................Lamanya ketuban pecah .................................. Kondisi ketuban ......................

IV. KEADAAN BAYI SAAT LAHIRLahir tanggal : ...........................jam ....................... sex ....................Kelahiran : tunggal/ gemeli

Nilai APGARTanda Nilai Jumlah 0 1 2

Denyut jantung Tidak ada < 100 > 100Usaha nafas Tidak ada Lambat Menangis kuatTonus otot Lumpuh Ekstremitas

fleksi sedikitGerakan aktif

Iritabilitas reflek

Tidak bereaksi Gerakan sedikit Reaksi melawan

Warna kulit Biru/ pucat Tubuh kemerahan, tangan dan kaki biru

Kemerahan

V. PEGKAJIAN FISIKBerat badan : ..................................Panjang badan : ..................................Suhu : ..................................Lingkar kepala : ..................................

Lingkar dada : ..................................Lingkar perut : ..................................Tubuh :

- Warna : .......................- Lanugo : .......................- Vernix : .......................

Head to ToeKepala :- Inspeksi : .......................- Palpasi : .......................Mata : .......................Telinga : .......................Hidung : .......................Mulut : .......................

Leher :- Inspeksi : .......................- Palpasi : .......................

Dada: Payudara Inspeksi : .....................................................

Palpasi : .....................................................Perkusi : .....................................................



Abdomen :- Inspeksi : .......................- Auskultasi : .......................- Palpasi : .......................- Perkusi : .......................- Keadaan tali pusat : ........................

Punggung :- Keadaan punggung : .......................- Fleksibilitas : .......................- Tulang punggung : .......................- Kelainan : .......................

Genetalia dan anus :- Mekonium : ........................- Kelainan : .......................

Ekstremitas :- Atas : ........................- Bawah : ........................- Kelainan : ........................- Pergerakan : ........................

VI. STATUS NEUROLOGIPemeriksaan refleks:- Refleks moro : .................... - Ballard score : ....................................- Rooting refleks : ....................- Sucking refleks : ....................Dll refleks primitif pada bayi baru lahirVII.NUTRISI

ASI/ PASI/ dll : ......................VIII. ELIMINASIBAB pertama, tanggal...................jam..............BAK pertama, tanggal...................jam..............IX. DATA PENUNJANGLaboratorium : .............................Radiologik : ............................

X. Diagnosa medikXI. Pengobatan

B. ANALISA DATA



1. ..........................................2. .........................................3. .........................................


NO DIAGNOSA RENCANA KEPERAWATANTUJUAN INTERVENSI RASION

AL

D. IMPLEMENTASI

TANGGAL/JAM

NO DX


PARAF/ NAMA


TGL/ JAM

NODIAGNOSA

EVALUASI

S :O :A :P :

Denpasar, ............................ 201..

Mengetahui,Pembimbing klinik/ CI Mahasiswa

(........................................) (............................................)NIP. NIM.


(...............................................) NIP.


”POST NATAL”


DENGAN......................................................................................

DI RUANG............................................

RS...............................................................

TANGGAL...........................................

A. PENGKAJIAN

I. IDENTITAS PASIEN PENANGGUNG/ SUAMINama : ………………………… Nama : ............... Umur : ………...…...………….. Umur : ...............Pendidikan : ........................................ Pendidikan : ...............Pekerjaan : ........................................ Pekerjaan : ...............Status perkawinan : ........................................ Alamat : ...............Agama : ....................................... Hub. Dgn Klien: ...............Suku : .......................................Alamat : .......................................No. CM : ........................................Tanggal MRS : .......................................Tanggal pengkajian : .......................................Sumber informasi : .......................................

II. RIWAYAT MASUK RUMAH SAKITKeluhan Utama (saat MRS dan sekarang).................................................................................................................................Riwayat persalinan sekarang..................................................................................................................................

Keadaan bayi sekarangBB .................... lingkar kepala ............................ lingkar dada .......................... Lingkar perut........................... dll ................................


Menarche : umur .......... Siklus : teratur ( ) tidak ( ) Banyaknya : ................... Lamanya: ............................. Keluhan : ...................




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

kelamin BB Pj

D. Riwayat Keluarga Berencana : Akseptor KB : jenis ............. Lama : ............. Masalah : ...................... Rencana KB : ......................


.....................................................................................................................2. Nutrisi/ metabolic

...................................................................................................................3. Pola eliminasi

.....................................................................................................................4. Pola aktivitas dan latihan



5. Oksigenasi: .....................................................................................................................6. Pola tidur dan istirahat .....................................................................................................................7. Pola perceptual ..................................................................................................................8. Pola persepsi diri ...................................................................................................................9. Pola seksual dan reproduksi .....................................................................................................................10.Pola peran-hubungan .....................................................................................................................11.Pola manajemen koping stress ...................................................................................................................

12. Sistem nilai dan keyakinan ....................................................................................................................

V. PEMERIKSAAN FISIKKeadaan umum GCS : ................................................ Tingkat kesadaran : ................................................ Tanda-tanda vital : TD.................. N.......... RR.......... T.......... BB : ....................... TB : .......... LILA :........

Head to toeKepala Wajah : Inspeksi : ...................................................... Palpasi : ......................................................








Abdomen :

Inspeksi : Linea : ................ Striae : ................. Luka SC: ………. Auskultasi : Bising Usus : ....................... Palpasi :

TFU : .................Kontraksi : .................Diastasis rectus abdominis : ..........................

Perkusi : ......................................................

Genetalia dan Perineum: Kebersihan : .................................................... Lokhea : .................................................... Karakteristik: ...................... Perineum : REEDA.......................................

Anus : Hemoroid : ....................................................

Ekstremitas: - Atas :

Oedema : ........................Varises : ........................CRT : ........................Kekuatan Otot : .......................Tonus : .......................

- Bawah :Oedema : .......................Varises : .......................CRT : .......................Tanda homan : .......................Pemeriksaan Reflek : .....................Kekuatan Otot : .......................Tonus : .......................

VI. DATA PENUNJANG Pemeriksaan Laboratorium : ................................ Pemeriksaan Radiologik : ...................................

VII. DIAGNOSA MEDISVIII. PENGOBATAN

B. ANALISA DATA


DS:


1. ..........................................2. .........................................3. .........................................

C. RENCANA KEPERAWATANNO DIAGNOSA RENCANA KEPERAWATAN

TUJUAN INTERVENSI RASIONAL

D. IMPLEMENTASI

TANGGAL/ JAM

NO DX


PARAF/ NAMA


TGL./ JAM

NO.DIAGNOSA

EVALUASI

S :O :A :P :

Denpasar, ............................ 201..


(........................................) (............................................)NIP. NIM.


(...............................................) NIP.


”GINEKOLOGI”


DENGAN......................................................................................

DI RUANG............................................

RS...............................................................

TANGGAL...........................

A. PENGKAJIAN

I. IDENTITAS PASIEN PENANGGUNG/ SUAMINama : ………………………… Nama : ............... Umur : ………...…...………….. Umur : ...............Pendidikan : ........................................ Pendidikan : ...............Pekerjaan : ........................................ Pekerjaan : ...............Status perkawinan : ........................................ Alamat : ...............Agama : ....................................... Hub. Dgn klien: ...............Suku : .......................................Alamat : .......................................No. CM : ........................................Tanggal MRS : .......................................Tanggal pengkajian : .......................................Sumber informasi : .......................................

II. RIWAYAT PENYAKITKeluhan Utama (saat MRS dan sekarang)..................................................................................................................................Riwayat Penyakit Sekarang.................................................................................................................................






No TahunUmur

kehamilan

Penyulit Jenis Penolong

Penyulit Laserasi Infeksi Perdarahan Jenis

kelamin BB Pj

D. Riwayat Keluarga Berencana : Akseptor KB : jenis ............. Lama : ............. Masalah : ......................

E. Riwayat Penyakit Klien dan Keluarga……………………………………………………………………………….


.....................................................................................................................2. Nutrisi/ metabolic .....................................................................................................................3. Pola eliminasi .....................................................................................................................4. Pola aktivitas dan latihan



5. Oksigenasi: ...................................................................................................................6. Pola tidur dan istirahat ...................................................................................................................7. Pola perceptual ...................................................................................................................8. Pola persepsi diri ....................................................................................................................9. Pola seksual dan reproduksi .....................................................................................................................10. Pola peran-hubungan .....................................................................................................................11. Pola manajemen koping stress .....................................................................................................................12. Sistem nilai dan keyakinan .....................................................................................................................

V. PEMERIKSAAN FISIKKeadaan umum

GCS : ................................................ Tingkat kesadaran : ................................................ Tanda-tanda vital : TD.................. N.......... RR.......... T.......... BB : ....................... TB : .......... LILA :........

Head to toeKepala Wajah :

Inspeksi : ...................................................... Palpasi : ......................................................








Abdomen : Inspeksi : ...................................................... Auskultasi : ......................................................

Palpasi : ...................................................... Perkusi : ......................................................

Genetalia dan perineum: Kebersihan : .................................................... Keputihan :........................................Karakteristik: ........................ Hemoroid : .................................................... Perdarahan : …………………………………


Oedema : ........................Varises : ........................CRT : ........................Kekuatan Otot : .......................Tonus : .......................

- Bawah :Oedema : .......................Varises : .......................CRT : .......................Refleks : .......................Kekuatan Otot : .......................Tonus : .......................

VI. DATA PENUNJANG Pemeriksaan Laboratorium : Pemeriksaan Radiologik :

VII. Diagnosa medisVIII. Pengobatan

B. ANALISA DATA


DS:


1. ..........................................2. .........................................3. .........................................



D. IMPLEMENTASI

TANGGAL/ JAM

NO. DX IMPLEMENTASI RESPON KLIEN/ EVALUASI

PARAF/ NAMA


TGL./ JAM

NO.DIAGNOSA

EVALUASI

S :O :A :P :

Denpasar, ............................ 201..


(........................................) (............................................)NIP. NIM.


(...............................................) NIP.

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