POLITEKNIK KESEHATAN RS dr.

SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

FORMAT ASKEP MATERNITAS ASUHAN KEPERAWATAN

PADA Ny. ....... DENGAN ......................................................

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

PENGKAJIAN

I. ANAMNESA

1. BIODATA

Nama : ............................................................

Umur : ............................................................

Pekerjaan : ............................................................

Status : ............................................................

Agama : ............................................................

Alamat : ............................................................

Nama suami : ............................................................

Pekerjaan : ............................................................

Alamat : ............................................................

Diagnosa medis : ............................................................

2. KELUHAN UTAMA

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3. RIWAYAT KESEHATAN

a. Riwayat Penyakit Saat Ini

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

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

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

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

b. Riwayat Kesehatan Masa Lalu

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

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

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

c. Riwayat Kesehatan Keluarga

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

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

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

4. RIWAYAT PERKAWINAN

a. Status perkawinan : ........................................

b. Umur pertama kali kawin : ........................................

c. Berapa kali kawin : ........................................

d. Berapa kali kawin yang sekarang : ........................................

5. RIWAYAT OBSTETRI

a. Menarche : ........................................

b. Haid teratur / tidak ; siklus : ........................................

c. Lama haid : ........................................

d. Keluhan : .........................................

e. Sifat dan banyaknya darah : .........................................

f. Amenorea : .........................................
 g. HPHT : .........................................

h. Taksiran persalinan : ........................................

6. RIWAYAT KEHAMILAN, PERSALINAN, NIFAS YANG LALU

a. Riwayat kehamilan yang lalu

Anak Jenis keluhan

No kehamilan berakhir (A, I, P, A, S, H/ M)
ke TM I, II, III

b. Riwayat persalinan yang baru

Hidup/ Umur Kelainan

No Persalinan ke BBL Cara lahir Penolong
Mati sekarang
 c. Riwayat nifas yang lalu

No Anak ke Keluhan saat nifas Pemberian ASI

7. RIWAYAT KEHAMILAN, PERSALINAN DAN NIFAS SAAT INI

a. Riwayat kehamilan sekarang

TGL UK LEOPOLD BJA TENSI ALBUMIN OEDEM/ TBJ LAIN- TERAPI

I - IV / BB REFLEK LAIN
(TT)
STATUS PRAESENS

Keadaan umum : ...........................................................................

TB / BB : ...........................................................................

Status gizi : ...........................................................................

Kelainan bentuk : ...........................................................................

TTV : TD .............................. Nadi .....................................

Suhu .......................... RR .....................................

Kepala : ........................................................................

Leher : ...........................................................................

Thoraks : ..........................................................................

Pulmo : ..........................................................................

Cor : ..........................................................................

Mammae : .........................................................................

Abdomen : .........................................................................

Hepar : .........................................................................

Lien : .........................................................................

Lain- lain : .........................................................................

Genitourinary : ........................................................................

Ekstremitas : ........................................................................

Lengan : ........................................................................

Kaki : Oedem ...................... Refleks ..............

 Toucher : Jam.................................Oleh................................

Indikasi : ...............................................................

Vulva/ vagina : ...............................................................

Pembukaan : ...............................................................

Efficement : ...............................................................

Ketuban : ...............................................................

Hodge : ..............................................................

Lain- lain/ keadaan luar biasa : ....................................................

Faktor resiko : ..................................................................................................

Kesimpulan : G.............. P............... A............... dengan UK ........................

b. Riwayat persalinan sekarang (diisi jika ibu partu atau nifas)

MRS tanggal : ..................................................................................................

Dikirim oleh : ..................................................................................................

Pemeriksaan pertama oleh : : .......................................................................................

Permulaan his : Hari/ tanggal : ........................................... Jam........................

Ketuban pecah : ................................................. Warna : ..................................

Lain- lain : ..................................................................................................

STATUS PRAESENS

Keadaan umum : ..................................................................................................

TB / BB : ..................................................................................................

Status gizi : ..................................................................................................

 Kelainan bentuk : ..................................................................................................

TTV : TD .................................. Nadi .....................................

Suhu .............................. RR .....................................

Kepala : ..................................................................................................

Leher : ..................................................................................................

Thoraks : ..................................................................................................

Pulmo : ..................................................................................................

Cor : ..................................................................................................

Mammae : ..................................................................................................

Abdomen : ..................................................................................................

Hepar : ..................................................................................................

Lien : ..................................................................................................

Lain- lain : ..................................................................................................

Genitourinary : ..................................................................................................

Ekstremitas : ..................................................................................................

Lengan : ..................................................................................................

Kaki : Oedem ......................................... Refleks .............................

STATUS OBSTETRI

Palpasi : ..................................................................................................

TFU : ..................................................................................................

DJJ : ..................................................................................................
 Letak anak : ..................................................................................................

Lain- lain : ..................................................................................................

Toucher : Jam................................. Oleh.................................................

Indikasi : ..................................................................................................

Vulva/ vagina : ..................................................................................................

Pembukaan : ..................................................................................................

Efficement : ..................................................................................................

Ketuban : ..................................................................................................

Hodge : ..................................................................................................

Lain- lain/ keadaan luar biasa : .........................................................................................

Partus dipimpin oleh : .................................Dengan pengawasan...............................

Dibantu : ..................................................................................................
 KALA I

Tgl/ Frekuensi Lama Kuat/

Pembukaan DJJ Keterangan
jam His His tidak

KALA II

TGL/
Lama His DJJ Keterangan
JAM

KU ibu

:................................................

∑ perdarahan :

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

Episiotomi/ tidak :

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

Tindakan lain :
 ....................................

KALA III

Tgl/ jam His Keterangan

Plasenta : Lengkap/ Tidak Ukuran : .............................................................................

Insertiae : ......................................................... Membran : .............................................

Keadaan luar biasa : .................................................................................................................

Keadaan FU 2 jam post partum : ..............................................................................................

Tanda- tanda Vital : TD .................................. Nadi .....................................

Suhu .............................. RR .....................................

Perineum : ..................................................................................................

Keadaan luar biasa/ lain- lain : ..................................................................................................

BAYI

Lahir jam :......................................... Laki- laki/ perempuan ........... Hidup/ Mati

Panjang badan : ....................... BBL ..................... LK ................... LD..........................

APGAR Score : ..............................................................................................................

Tanda- tanda Vital : Nadi ............................ Suhu ........................ RR ............................

Caput succendaneum : ..............................................................................................................

Cephal hematom : ..............................................................................................................

Anus : ada / tidak

Kelainan/ lain- lain : ...........................................................................................................

c. Riwayat Nifas Sekarang

KALA IV

Tgl/ TFU Kontraksi Lochea Keterangan Terapi

jam
8. RIWAYAT KB

KB yang sebelumnya : ..................................................................................................

Keluhan : ..................................................................................................

Rencana KB yang akan datang : ...................................................................................

9. RIWAYAT PSIKOSOSIAL SPIRITUAL

Konsep diri

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

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

Sosial

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

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

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

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

Spiritual

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10. POLA AKTIVITAS SEHARI- HARI

Makan : ..................................................................................................

Di rumah : ..................................................................................................
 Di RS : ..................................................................................................

Minum : ..................................................................................................

Di rumah : ..................................................................................................

Di RS : ..................................................................................................

Eliminasi : ..................................................................................................

Di rumah : ..................................................................................................

Di RS : ..................................................................................................

Istirahat / tidur : ..................................................................................................

Di rumah : ..................................................................................................

Di RS : ..................................................................................................

Aktivitas : ..................................................................................................

Di rumah : ..................................................................................................

Di RS : ..................................................................................................

II. PEMERIKSAAN PENUNJANG

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III. OBSERVASI BAYI

keadaan umum
berat BAK/ Lain-
Tgl/ jam (TTV, refleks Minum
badan BAB lain
primitif)

PEMERIKSAAN PENUNJANG
TERAPI
 ANALISA DATA

Nama Pasien : ............................................................. No register : ...........................

Diagnosa Medis : ............................................................ Umur : ...........................

No Tanggal/ Data Penunjang MASALAH PENYEBAB

jam
 DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien : ............................................................. No register : ...........................

Diagnosa Medis : ............................................................ Umur : ...........................

No Tanggal Diagnosa keperawatan tanggal teratasi TTD

muncul
 CATATAN KEPERAWATAN

Nama Pasien : ............................................................. No register : ...........................

Diagnosa Medis : ............................................................ Umur : ...........................

No Tgl no Jam Tindakan evaluasi proses TTD

dx keperawatan
kep
 FORMAT CATATAN PERKEMBANGAN

NAMA PASIEN :
UMUR :
DX. MEDIS :

NO. DX. TANGGAL/ CATATAN PERKEMBANGAN TTD.

KEP JAM