FORMAT PENGKAJIAN

( KEPERAWATAN MATERNITAS / OBSTETRI )

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

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

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

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2. Riwayat Kebidanan Sekarang
a. Riwayat Antenatal/ Kehamilan
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b. Riwayat Intranatal/ Persalinan

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c. Riwayat Post Natal / Nifas

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d. Riwayat Bayi Baru Lahir

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3. Riwayat Kebidanan Masa Lalu
a. Riwayat Haid
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b. Riwayat Perkawinan
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c. Riwayat Kehamilan, Persalinan dan Nifas BBL

Riwayat Kehamilan Persalinan Nifas BBL
Anak Ke

d. Riwayat KB
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e. Kelainan Sistem Reproduksi
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4. Riwayat Kesehatan keluarga

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5. Riwayat Psikososial dan Status Spiritual

a. Riwayat Psikologis
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b. Aspek Sosial
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c. Aspek Spiritual/ Sistem Nilai Kepercayaan

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6. Pola Kebiasaan Sehari – hari

a. Pola Nutrisi
1). Sebelum Sakit
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2). Saat Sakit

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b. Pola Eliminasi
1). Buang Air Besar
a). Sebelum Sakit
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b). Saat Sakit

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2). Buang Air Kecil
a). Sebelum Sakit
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b). Saat Sakit

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c. Pola Kebersihan diri
1). Sebelum Sakit
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2). Saat Sakit

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d. Pola Aktivitas, Latihan dan Bermain

1). Sebelum Sakit
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2). Saat Sakit

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e. Pola Istirahat dan Tidur

1). Sebelum Sakit
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2). Saat Sakit

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7. Pemeriksaan Fisik
Keadaan Umum
a. Keadaan Sakit
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b. Tanda – tanda Vital

Tensi : …………………………. Nadi : ………………………………….
RR : …………………………. Suhu : ………………………………….
BB : …………………………. TB : ………………………………….
LL : …………………………. LK : ………………………………….

c. Pemeriksaan Cepalo Caudal

1). Kepala dan Rambut
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2). Hidung
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3). Telinga
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4). Mata
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5). Mulut, Gigi, Lidah, Tonsil dan Pharing

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6). Leher dan Tenggorokan

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7). Dada/ Thorak

a). Pemeriksaan Paru
(1). Inspeksi
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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b). Pemeriksaan Jantung

(1). Inspeksi
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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8). Payudara
(a). Inspeksi
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(b). Palpasi
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9). Pemeriksaan Abdomen

(a). Inspeksi
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(b). Auskultasi
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(c). Palpasi
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(d). Perkusi
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10). Genetalia dan Anus

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11). Ekstrimitas, Kuku dan Kekuatan Otot

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12). Pemeriksaan Neurologi

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

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11. Genogram

Banyuwangi, ………, ………….. 20…

Mahasiswa
 ANALISA DATA

Nama Pasien :
No. Register :

NO KELOMPOK DATA MASALAH ETIOLOGI

 DIAGNOSA KEPERAWATAN

Nama Pasien :
No. Register :

TANGGAL TANGGAL TANDA

DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
No. Register :
TG NO TUJUAN KRITERIA HASIL INTERVENSI RASIONAL TT
L
 20

CATATAN KEPERAWATAN

Nama Pasien :
No. Register :
NO
TANGGAL JAM TINDAKAN KEPERAWATAN TT
DX

CATATAN PERKEMBANGAN
 21

Nama Pasien :
No. Register :

NO
TANGGAL TANGGAL TANGGAL
DX

FORMAT PENGKAJIAN
( KEPERAWATAN MATERNITAS / GINEKOLOGI )

C. IDENTITAS KLIEN
 22

Biodata
m. Nama : ……………………………………………….
n. Umur : ……………………………………………….
o. Jenis Kelamin : ……………………………………………….
p. Alamat : ……………………………………………….
q. Status perkawinan : ……………………………………………….
r. Agama : ……………………………………………….
s. Pendidikan : ……………………………………………….
t. Pekerjaan : ……………………………………………….
u. No. Register : ……………………………………………….
v. Tanggal MRS : ……………………………………………….
w. Tanggal Pengkajian : ……………………………………………….

Biodata Penanggungjawab
f. Nama Suami : ……………………………………………….
g. Umur : ……………………………………………….
h. Pendidikan : ……………………………………………….
i. Pekerjaan : ……………………………………………….
j. Alamat : ……………………………………………….

D. PENGKAJIAN
1. Keluhan Utama
a. Keluhan saat MRS
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………

b. Keluhan saat Pengkajian

……………………………………………………………………………………………
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……………………………………………………………………………………………

2. Riwayat Penyakit Sekarang

…………………………………………………………………………………………………
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 23

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3. Riwayat Peyakit Dahulu

…………………………………………………………………………………………………
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4. Riwayat Penyakit Keluarga

a. ……………………………………………………………………………………………
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…………………………………………………………………………………………………
b. Genogram

5. Riwayat Kebidanan Masa Lalu

a. Riwayat Haid
…………………………………………………………………………………………………
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b. Riwayat Perkawinan
……………………………………………………………………………………………………………………………………………
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………………………………………………………………………………………………………………………………………
c. Riwayat Kehamilan, Persalinan dan Nifas BBL
Riwayat Kehamilan Persalinan Nifas BBL
 24

Anak Ke

d. Riwayat KB
……………………………………………………………………………………………………………………………………………
……………………………..………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………
……………………………..………………………………………………………………………………….
………………………………………………………………………….
……………………………………………………………………………………………….
………………………………………………………………………………………………..
e. Kelainan Sistem Reproduksi
……………………………………………………………………………………………………………………………………………
……………………………..………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………
……………………………..………………………………………………………………………………….
…………………………………………………………………………

6. Riwayat Psikososial dan Status Spiritual

a. Riwayat Psikologis
…………………………………………………………………………………………………
………………………………………………………………………..
……………………………….………………………………………………….
…………………………………………………..
…………………………………………………………………………………………………
………..……………..
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b. Aspek Sosial
 25

…………………………………………………………………………………………………
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………………………………………………………………………..………………………

c. Aspek Spiritual/ Sistem Nilai Kepercayaan

…………………………………………………………………………………………………
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…………………………………………………………………………………
………………………………………………………………………..………………………
………………………………………………………………………..………………………
………………………………………………………………………..………………………
7. Pola Kebiasaan Sehari – hari
a. Pola Nutrisi
1). Sebelum Sakit
………………………….
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………..
………………………………………………………………………………….
……………………………………………………………………………………………
……………………………………………………………………………..
………………………………………

2). Saat Sakit

………………………….
……………………………………………………………………………………………
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 26

b. Pola Eliminasi
1). Buang Air Besar
a). Sebelum Sakit
………………………….
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b). Saat Sakit

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2). Buang Air Kecil
a). Sebelum Sakit
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b). Saat Sakit

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 27

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c. Pola Kebersihan diri

1). Sebelum Sakit
………………………….
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2). Saat Sakit

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d. Pola Aktivitas, Latihan dan Bermain

1). Sebelum Sakit
………………………….
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 28

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2). Saat Sakit

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e. Pola Istirahat dan Tidur

1). Sebelum Sakit
………………………….
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2). Saat Sakit

………………………….
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8. Pemeriksaan Fisik
Keadaan Umum
 29

a. Keadaan Sakit
………………………….
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b. Tanda – tanda Vital

Tensi : …………………………. Nadi : ………………………………….
RR : …………………………. Suhu : ………………………………….
BB : …………………………. TB : ………………………………….
LL : …………………………. LK : ………………………………….

c. Pemeriksaan Cepalo Caudal

1). Kepala dan Rambut
………………………….
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2). Hidung
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 30

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3). Telinga
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4). Mata
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5). Mulut, Gigi, Lidah, Tonsil dan Pharing

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6). Leher dan Tenggorokan

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 31

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7). Dada/ Thorak

a). Pemeriksaan Paru
(1). Inspeksi
………………………….
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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 32

………………………….
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b). Pemeriksaan Jantung

(1). Inspeksi
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(2). Palpasi
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(3). Perkusi
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(4). Auskultasi
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 33

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8). Payudara
(a). Inspeksi
………………………….
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(b). Palpasi
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9). Pemeriksaan Abdomen

(a). Inspeksi
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(b). Auskultasi
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(c). Palpasi
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 34

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(d). Perkusi
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10). Genetalia dan Anus
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11). Ekstrimitas, Kuku dan Kekuatan Otot

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12). Pemeriksaan Neurologi

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 35

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

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 36

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Banyuwangi, ………, ………….. 20…

Mahasiswa

ANALISA DATA

Nama Pasien :
No. Register :

NO KELOMPOK DATA MASALAH ETIOLOGI

 37

DIAGNOSA KEPERAWATAN

Nama Pasien :
No. Register :

TANGGAL TANGGAL TANDA

DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
38
 RENCANA ASUHAN KEPERAWATAN

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

Nama Pasien :
No. Register :
NO T
TANGGAL JAM TINDAKAN KEPERAWATAN
DX T

CATATAN PERKEMBANGAN
Nama Pasien :
No. Register :

NO
TANGGAL TANGGAL TANGGAL
DX

FORMAT PENGKAJIAN
(Perinatologi)

A. PENGKAJIAN
1. BIODATA
 a. Nama Bayi : ..................................................................
b. Umur/Tanggal lahir : ..................................................................
c. Jenis Kelamin : ..................................................................
d. Nomor Register : ..................................................................
e. Tanggal MRS : ..................................................................
f. Tanggal Pengkajian : ..................................................................
g. Diagnos medis : ..................................................................

PENAGGUNG JAWAB
a. Nama Bayi : ..................................................................
b. Umur/Tanggal lahir : ..................................................................
c. Jenis Kelamin : ..................................................................
d. Agama : ..................................................................
e. Pekerjaan : ..................................................................
f. Pendidikan terakhir : ..................................................................
g. Status perkawinan :...................................................................
h. Suku bangsa : ..................................................................

2. KELUHAN UTAMA / ALASAN MASUK RUMAH SAKIT

a. Keluhan saat MRS
..............................................................................................................................................
..............................................................................................................................................
..................................................................
b. Keluhan saat pengkajian
..............................................................................................................................................
..............................................................................................................................................
.....................................................................
3. RIWAYAT PENYAKIT SEKARANG
a. Kronologis penyakit pasien (dirumah, UGD/poli)
..............................................................................................................................................
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4. RIWAYAT PENYAKIT MASA LALU

 a. Antenatal (riwayat kehamilan)
 Status GPA : G...P...A...
 Usia kehamilan : .......................................................................
 Penggunaan obat – obatan selama kehamilan : ....................................
 Imunisasi TT : .......................................................................
 Prenatal care : ........................................................................
 Komplikasi penyakit selama kehamilan : ..............................................

b. Natal (riwayat persalinan sekarang)

 Penolong persalinan : .........................................................................
 Tempat persalinan : .........................................................................
 Jenis persalinan : .....................................................................
 Air ketuban : ........................................................................
 Lama persalinan kala II : ......................................................................
 Keadaan tali pusat : .......................................................................

c. Post natal (neonatus)

 APGAR : 1’ dan 5’ : ...............................................................
 Resusitasi : ................................................................
 Pemberian O2 : ..............................................................
 Pernapasan spontan/tidak : ...............................................................
 Frekuensi : ...............................................................
 Teratur/tidak : .............................................................
 Menangis : ...............................................................

5. RIWAYAT KESEHATAN KELUARGA

a. Genogram (3 generasi)

b. Kesehatan keluarga
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............
6. RIWAYAT IMUNISASI
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
............................................

7. POLA KEBIASAAN SEHARI-HARI

a. Pola nutrisi
 Jenis makanan/minuman : ...................................................................
 Frekuensi : ....................................................................
 Jumlah : .....................................................................
 Cara pemberian : ....................................................................
 Infus/jumlah : .................................................................

b. Pola eliminasi
BAK
 Frekuensi/ jumlah :..................................................................
 Warna : ....................................................................
BAB
 Frekuensi : ....................................................................
 Warna : ...................................................................
 Konsistensi : .............................................................

c. Pola istirahat dan tidur

 Lamanya : ...................................................................
 Keadaan waktu tidur : ..................................................................

8. PEMERIKSAAN FISIK
a. Keadaan umum
...............................................................................................................................................
...............................................................................................................................................
.................................................

b. Tanda – tanda vital

Nadi : ....................................... RR : .............................
Suhu : ....................................

c. Tatus gizi / pertumbuhan

  Berat badan : ......................................................................
 Panjang badan : .......................................................................
 Lingkar lengan : .......................................................................
 Lingkar dada : .......................................................................
 Lingkar kepala : .........................................................................

d. Pemeriksaan cepalo caudal

1. Kepala dan rambut
 Ubun – ubun kecil : .............................................................
 Caput Succedenum : ..............................................................
 Chepal hematoma : ............................................................
 Ukuran lingkar kepala : ............................................................
 Fronto occipito : .........................................................

2. Mata
 Bentuk/simetris : ..........................................................................
 Kotoran : ..............................................................................
 Konjungtiva : ...............................................................................
 Sklera : .............................................................................
 Palpebra :..........................................................................
3. Hidung
 Lubang hidung : ..........................................................
 Pernapasan cuping hidung : ........................................................
 Sekret : ..........................................................
 Kelainan :...........................................................
 Refleks grabella :............................................................

4. Telinga
 Bentuk : .....................................................
 Letak telinga terhadap mata : .....................................................
 Pengeluaran cairan : .....................................................
 Kelainan :......................................................
 Refleks startel :......................................................

5. Rongga mulut dan tenggorokan

 Warna bibir : ..............................................................................
 Palatum : ...............................................................................
 Lidah : ..............................................................................
  Gigi : ...............................................................................
 Refleks sucking : .............................................................................
 Refleks rooting : .............................................................................
 Refleks gawn : ..............................................................................

6. Leher
 Pembengkakan kelenjar : ...............................................................
 Kelenjar tiroid : ..............................................................
 Reflek tonik neck : ...............................................................
 Kelainan :.............................................................

7. Dada/thorak
a. Pemeriksaan paru
1. Inspeksi
............................................................................................................................
...............................................................................

2. Palpasi
............................................................................................................................
................................................................................
3. Perkusi
............................................................................................................................
...............................................................................
4. Auskultasi
............................................................................................................................
...............................................................................
b. Pemeriksaan jantung
1. Inspeksi
.............................................................................................................................
..............................................................................
2. Palpasi
.............................................................................................................................
...............................................................................
3. Perkusi
.............................................................................................................................
..............................................................................
4. Auskultasi
 ............................................................................................................................
................................................................................

8. Abdomen
1. Inspeksi
 Keadaan tali pusat : .....................................................
 Perdarahan tali pusat : .....................................................
 Tanda – tanda infeksi : .....................................................
 Hernia umbilikalis :......................................................
 Kelainan :......................................................
2. Auskultasi
..................................................................................................................................
...................................................................................
3. Palpasi
..................................................................................................................................
...................................................................................

4. Perkusi
..................................................................................................................................
...................................................................................

9. Ekstrimitas
 Gerakan tangan : ........................................................................
 Reflek grasping : .........................................................................
 Refleks moro: ..........................................................................
 Refleks grasping : .........................................................................
 Refleks menari : ..........................................................................
 Jari-jari tangan : .........................................................................
 Akrosianosis : ........................................................................

10. Genetalia dan anus

1. Laki-laki
 Lubang uretra : .........................................................................
 Testis : ........................................................................
 Lubang anus : ........................................................................
2. Perempuan
 Labia mayora : .........................................................................
 Lubang vagina: ..........................................................................
  Lubang uretra : .........................................................................
 Lubang anus : .........................................................................

11. Keadaan punggung

 Spina bifida : ...............................................................................
 Refleks peres : ...............................................................................

12. Integumen
 Warna kulit : ...............................................................................
 Tanda lahir : ..............................................................................
 Kelainan : ...............................................................................

9. PEMERIKSAAN PENUNJANG
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
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....................................................................................................................................................
......................................................................................................

10. PENATALAKSANAAN
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
.........................................................................................

Banyuwangi,......................
Mahasiswa

(....................................)
 ANALISA DATA

Nama Pasien :
No. Register :

NO KELOMPOK DATA MASALAH ETILOGI

 DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien :
No. Register :

TANGGAL TANGGAL TANDA

DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

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

Nama Pasien :
No. Register :
NO T
TANGGAL JAM TINDAKAN KEPERAWATAN
DX T

CATATAN PERKEMBANGAN

Buku Panduan Praktek Lab Klinik Keperawatan Page 53

Nama Pasien :
No. Register :

NO
TANGGAL TANGGAL TANGGAL
DX

Buku Panduan Praktek Lab Klinik Keperawatan Page 54

 FORMAT RESUME
( KEPERAWATAN MATERNITAS)

A. IDENTITAS KLIEN
Biodata
a. Nama : ………………................................. Agama : …………………………………….
b. Umur : ……………..................................... Pekerjaan :……………………………………..
c. Alamat : ……………….................................. No. Register :……………………………….........
d. Status perkawinan : ……………….................................. Tanggal Pengkajian : …………………………………....
e. Diagnosa Medis : ……………………………………….
NO S O A P I E R

Buku Panduan Praktek Lab Klinik Keperawatan Page 55

 Lampiran 2

Buku Panduan Praktek Lab Klinik Keperawatan Page 56