ASUHAN KEPERAWATAN MATERNITAS PADA NY. ....

DENGAN DIAGNOSA MEDIS ..............................................................................................

DI RUANG............................................................................................
Tanggal...................................................

I. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : ......................................................................................... ......
Umur : ......................................................................................... ......
Agama : ......................................................................................... ......
Jenis Kelamin : ........................................................................................... ....
Status : ........................................................................................... ....
Pendidikan :............................................................................................ ....
Pekerjaan : ............................................................................................ ...
Suku Bangsa :............................................................................................ ....
Alamat : .......................................................................................... .....
Tanggal Masuk : ........................................................................................... ....
Tanggal Pengkajian : ........................................................................................... ....
No. Register : ............................................................................................. ..
Diagnosa Medis : ............................................................................................ ...

b. Identitas Penanggung Jawab

Nama : ............................................................................................ ...
Umur : ............................................................................................. ..
Hub. Dengan Pasien : ........................................................................................... ...
Pekerjaan : ............................................................................................. ..
Alamat : .............................................................................................. .

2. Riwayat Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
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2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini
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b. Riwayat kehamilan dan persalinan yang lalu

Keadaan
Jenis Masalah
No Tahun Penolong Jenis Bayi Waktu
Persalinan Kehamilan
Lahir

Keterangan:
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Pengalaman menyusui : ya/tidak, Berapa lama :
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c. Riwayat Ginekologi
1. Masalah ginekologi
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2. Riwayat KB
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d. Riwayat Kehamilan Saat ini

HPHT :.................................................................................................................
Taksiran Partus :.................................................................................................................
BB Sebelum Hamil :...................Kg
TD Sebelum hamil :...................mmHg
TD Berat TFU Letak/Presentasi DJJ Usia Keluhan Data
Badan Janin Gestasi Lain
II. PENGKAJIAN BIO-PSIKOSOSIAL (Menurut Calista Roy) :
a. Pengkajian ibu bersalin
1. Kebutuhan Fisiologis
a) Aktivitas dan istirahat
Pola Tidur : kebiasaan tidur, lama …......…..jam/hari, frekuensi ……................…..
Pola tidur saat ini :
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Keluhan ketidaknyamanan : ya / tidak, lokasi ………...................................………
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b) Nutrisi
Asupan nutrisi :
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nafsu makan : baik / kurang / tidak ada
Asupan cairan :
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Eliminasi
Urin : kebiasaan BAK
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BAB : kebiasaan BAB
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c) Cairan dan elektrolit
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d) Oksigen
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e) Proteksi
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f) Pengaturan suhu
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g) Pengaturan system endokrin
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h) Fungsi neurologis
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2. Konsep diri yaitu:
1) Gambaran diri
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2) Ideal diri
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3) Fungsi peran
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3. Interdependend (Kemandirian)
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4. Budaya (kaitannya dengan kepercayaan dan adat yang berlaku di masyarakat pada ibu
hamil kaitannya dengan pantangan-pantangan )
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III. DATA UMUM KESEHATAN SAAT INI
 Status obstetric :
G…..P……A……H……..................................................................................................
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 Keadaan umum : ….............................................……….
 Kesadaran:.........................................................................................................………..B
B/TB: ……...............….................................................................................................
 Tanda Vital :
 Tekanan darah ……....……..mmHg
 Nadi ………x/menit
 Suhu ……….°C
 Pernafasan …………….x/menit
 Kepala Leher
o Kepala :
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o Mata :
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o Hidung :
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o Mulut :
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o Telinga :
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o Leher :
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 Dada
o Jantung :
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o Paru :
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o Payudara :
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o Putting susu :
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o Pengeluaran ASI :
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 Abdomen
 Uterus:
o Tinggi fundus uterus : ….........cm
o Kontraksi : Ya / tidak
o Leopold I : Kepala / bokong / kosong
o Leopold II : Kanan: punggung / bagian kecil / bokong / kepala
Kiri : punggung / bagian klecil / bokong / kepala
o Leopold III : Kepala / bokong / kosong
Penurunan kepala : sudah / belum
o Leopold IV : bagian masuk PAP.........................................................
 Pigmentasi
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  Linea nigra
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 Striae
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 Fungsi pencernaan
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 Perineum dan genital
 Vagina : varises : ya / tidak
 Keputihan :............
Jenis / warna:.............................................................................................................
Konsistensi :..............................................................................................................
Bau :..........................................................................................................................
 Hemorhoid :
derajat :................
lokasi :.......................................................................................................................
Berapa lama :.............................................................................................................
Nyeri : ya/tidak
 Ekstremitas
 Ekstremitas atas :
Edema : ya/tidak, lokasi ……..............................................................................……
Varises : ya/tidak, lokasi …….............................................................................……
 Ekstremitas bawah
Edema : ya/tidak, lokasi ……..............................................................................……
Varises : ya/tidak, lokasi …….............................................................................……
Reflek patella : + / -
 Keadaan mental
 Adaptasi psikologis :
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  Penerimaan terhadap kehamilan :
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 Obat-obatan yang di konsumsi saaat ini
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 Hasil pemeriksaan penunjang
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IV. PENGKAJIAN INTRANATAL
A. PENGKAJIAN KALA I
1. Mulai persalinan : tanggal ………..................…….. jam ………….................….
2. Tanda dan Gejala :
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3. Tanda-tanda vital : TD …..........…. MmHg, Nadi …….....…… x/menit, Suhu
……….°C, Pernafasan …...…. x/menit
4. Lama kala I :....…………… jam ………...….. menit
5. Keadaan Psikososial :
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6. Tindakan :
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7. Pengobatan :
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8. Observasi kemajuan persalinan :
Tanggal / jam Kondisi Utama (his, DJJ Keterangan
pembukaan portio, efficement,
hodge)
B. ANALISA DATA

NO SIGN/SYMPTOM ETIOLOGI PROBLEM

C. DIAGNOSA KEPERAWATAN
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D. RENCANA ASUHAN KEPERAWATAN
NO. TUJUAN/KRITERIA RASIONAL
INTERVENSI
DX HASIL
E. IMPLEMENTASI

NamaPasien : No RM :
Umur : Dx. Medis :
HARI/TGL/ NO.
IMPLEMENTASI RESPONHASIL TTD
JAM DX.
XI. EVALUASI
Namapasien : No RM :
Umur : DxMedis :
HARI/TGL/ NO. EVALUASI TTD
JAM DX
B. PENGKAJIAN KALA II
1. Kala II dimulai : tanggal ………...................... jam …..................……
2. Tanda-tanda vital : TD ……..........….. mmHg, Nadi …………. x/menit,
Suhu ……..……°C, Pernafasan …….......… x/menit
3. Lama Kala II …………. Jam ………… menit
4. Tanda dan gejala :
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Upaya meneran :
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5. Keadaan Psikososial :
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6. Kebutuhan khusus :
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7. Tindakan :
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 I. CATATAN KELAHIRAN
1. Bayi lahir jam : …………….
2. Nilai APGAR menit I ………. Menit V …………..
3. Perineum (utuh / episiotomy / ruptur), jika rupture, tingkat …….................…….
4. Bonding ibu dan bayi ……….............................................................……………
5. Tanda-tanda vital : TD ………… mmHg, Nadi ………. x/menit, Suhu
……….°C, Pernafasan ……… x/menit
6. Pengobatan ……………...............................................................................……..
II. ANALISA DATA

NO SIGN/SYMPTOM ETIOLOGI PROBLEM

III. DIAGNOSA KEPERAWATAN
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 IV. RENCANA ASUHAN KEPERAWATAN

NO. TUJUAN/KRITERIA RASIONAL

INTERVENSI
DX HASIL
 V. IMPLEMENTASI

HARI/TGL/ NO.
IMPLEMENTASI RESPONHASIL TTD
JAM DX.
 VI. EVALUASI

HARI/TGL/ NO. EVALUASI TTD

JAM DX
C. PENGKAJIAN KALA III
1. Tanda dan Gejala :
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2. Plasenta lahir jam : ……………….........................................................................
3. Cara lahir plasenta :………………........................................................................
4. Karakteristik plasenta :
Ukuran : ……….. cm x ……….. cm x ……….. cm
Panjang tali pusat : ………….. cm
Jumlah pembuluh darah : ………… arteri ……….. vena
Kelainan : …….....................................................................................…………..
5. Perdarahan : ………………. ml
6. Tindakan :
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7. Pengobatan :
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 B. ANALISA DATA

NO SIGN/SYMPTOM ETIOLOGI PROBLEM

C. DIAGNOSA KEPERAWATAN
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 D. RENCANA ASUHAN KEPERAWATAN

NO. TUJUAN/KRITERIA RASIONAL

INTERVENSI
DX HASIL
 E. IMPLEMENTASI

HARI/TGL/ NO.
IMPLEMENTASI RESPONHASIL TTD
JAM DX.
 F. EVALUASI

HARI/TGL/ NO. EVALUASI TTD

JAM DX
D. PENGKAJIAN KALA IV
1. Mulai jam :…………..............................................................................................
2. Tanda-tanda vital : TD: ………...........… mmHg, Nadi ……....…. x/menit,
Suhu ……....….°C, Pernafasan ……...… x/menit
3. keluhan Pasien :
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4. Kontraksi uterus : ……..............................................................................……….
5. Perdarahan :..............………… ml, karakteristik : …………...........................….
6. Bonding ibu dan bayi :…...............................................................……………….
7. Tindakan : …………................................................................................………..

E. BAYI
1. Bayi lahir tanggal / jam :...................................................................……………..
2. Jenis kelamin :...............................................................................….....…………
3. Nilai APGAR :…………….
4. BB / PB / lingkar kepala bayi :……… gram /……… cm /………. Cm
5. Karakteristik khusus bayi : …........................................................………………
6. Kaput : suksedaneum / cephalhematom
7. Suhu : ...................………. °C
8. Anus : berlubang / tertutup
9. Perawatan tali pusat : …........................................................................………….
10. Perawatan mata : …....................................................................................………
 F. TABEL PEMANTAUAN KALA IV :
Jam Kandung
Waktu Tensi Nadi Suhu TFU Kontraksi Perdarahan
ke Kemih

2
 SYAIR OBSTETRI

Tanggal / jam Keterangan

Tanggal................

Jam...................... S:

 Mules-mules bertambah sering

 Klien ingin meneran

O: Tanda vital ;

 Status generalis : dbn

 Status obstetric : tfu ………. cm, punggung ki/ka,
presentasi kepala, djj ……. x/menit, kuat, teratur, PBJ
…….. gr
 His .........x/....”/....”/kuat dan teratur, relaksasi baik
 PD : pembukaan lengkap, porsio tidak teraba, ketuban +/-,
kepala H III/IV, uuk kidep/kadep, tidak ada hambatan jalan
lahir, blood slym (+).

A:

 Ibu partus kala II, G …… A ….. P …….

 Janin hidup, presentasi kepala, tunggal / gemeli.

P:

 Pecahkan ketuban
 Pimpin meneran
Jam Ketuban dipecahkan,
………………….
Warna ………. Jumlah ………… cc, bau ………….

Jam Pimpin meneran

………………....
Ibu dipimpin meneran sesuai dengan datangnya his. Kepala turun
menurut jalan lahir, sehingga tampak di vulva.

Tampak perineum meregang, tipis kebiruan, jarak kepala –

perineum minimal (dilakukan episiotomy medio lateral sesuai
indikasi).

Kepala mengadakan defleksi maksimal.

 Berturut-turut lahir : uub, dahi, mulut, dagu dan seluruh kepala.
Kepala mengadakan paksi luar.

Dengan pegangan biparietal dan tarikan ke bawah dan ke atas

lahir bahu depan dan belakang.

Kemudian dilahirkan trochanter depan, belakang, bokong dan

seluruh kaki.

Jam Lahir bayi : laki-laki / perempuan

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Berat ……… gram, PB …….. cm, A/S…………….

Jam Lahir plasenta :

……………….
 Spontan, lengkap
 Berat ………. Gr, ukuran ………..x ………… x………. cm
 Panjang tali pusat ………. Cm
 Insersio ………… cm
 Robekan ……………

Klien mendapat methergin 0,2 mg IM (sesuai indikasi).

Kemudian dilakukan perineografi dengan beberapa simpul cat-

gut.

Mengetahui Bidan Jaga

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 LEMBAR PENGESAHAN

Laporan ini telah diperiksa dan disetujui pada:

Hari/Tanggal :

Ruangan :

Nama Mahasiswa : Fitriani Indraswari

Nim : 056STYJ18

Mengetahui:

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