Lampiran 1.docx

Lampiran 1 FORMAT PENGKAJIAN ANTENATAL

Nama Klien

:.......................................... Nama Mahasiswa :............................................

Alamat

:.......................................... Tanggal Pengkajian ..........................................

Umur

:........................................... Diagnosa Medik ...............................................

Pekerjaan

:.......................................... HPHT ...............................................................

Agama

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

Suku Bangsa

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

I. Persepsi dan harapan klien sehubungan dengan kehamilan 1. Mengapa ibu datang ke klinik ? ....................................................................................................................................................... .......................................................................................................................................................

2. Apakah kehamilan ini menimbulkan perubahan terhadap kehidupan sehari-hari ? Bila ya bagaimana ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................

3. Harapan apa yang ibu inginkan selama masa kehamilan ? ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................

4. Ibu tinggal dengan siapa ? .......................................................................................................................................................

5. Siapa orang yang terpenting bagi ibu ? .......................................................................................................................................................

6. Dengan kunjungan ibu ke klinik, dampak apa yang terjadi dalam keluarga ? ....................................................................................................................................................... .......................................................................................................................................................

7. Apakah suami (orang terdekat) mau menemani untuk datang ke klinik ? .......................................................................................................................................................

8. Rencana melahirkan dimana ? .......................................................................................................................................................

9. Apakah ibu merencanakan untuk menyusui bayinya ? .......................................................................................................................................................

10. Apakah ibu sudah di imunisasi ? kapan dan apa jenisnya ? ....................................................................................................................................................... .......................................................................................................................................................

11 Apakah ibu memelihara kucing ? Siapa yang membersihkan kotoran kucingnya ? ....................................................................................................................................................... .......................................................................................................................................................

II. KEBUTUHAN DASAR KHUSUS 1. Kenyamanan, istirahat, tidur a. Ketidaknyamanan 1. Apakah terjadi gangguan kenyamanan sejak terjadinya kehamilan ? Ya................................................... Tidak............................................................................. Jelaskan.................................................................................................................................. ...................................................................................................................................................

Apa yang telah ibu lakukan untuk mengatasi ketidaknyamanan ?......................................... .................................................................................................................................................. .................................................................................................................................................

Apakah hilang dengan pengobatan ?...................................................................................... ................................................................................................................................................ ................................................................................................................................................

Apa yang ibu inginkan dari perawat untuk menghilangkan rasa tidak nyaman tersebut ? .......................................................................................................................................................... .......................................................................................................................................... b. Istirahat -tidur

1. Adakah gangguan untuk istirahat-tidur selama kehamilan ? Ya............... Tidak................. Bila ya, jelaskan........................................................................................................................ .......................................................................................................................................................... ........................................................................................................................................

2. Apa yang telah ibu lakukan pada masa lalu untuk mendapatkan istirahat / tidur yang cukup? Apakah hal ini berhasil...........................sering...........................kadang-kadang.................... Jarang......................................................................

3. Apakah ibu suka tidur siang ? Ya........................................................................... Tidak......................................................... Bila ya berapa jam/hari ?.........................................................................................................

c. Hygiene Prenatal 1. Jelaskan cara mandi............................................................................................................. Berapa kali sehari................................................................................................................. 2. Bagaimana cara membersihkan gigi.................................................................................... Berapa kali sehari................................................................................................................ 3. Bagaimana biasanya kulit ibu........................kering...............................berminyak............ ........................normal 4. Adakah sesuatu digunakan untuk kulit ibu ? ..................................muka............................................badan.................................perut

2. Keselamatan a. Pergerakan Adakah kesulitan tentang berjalan ? Ya.............................Tidak................................ Jelaskan.................................................................................................................................. .............................................................................................................................................. Bagaimana mengatasinya ?................................................................................................. ................................................................................................................................................

b. Penglihatan 1. Adakah gangguan penglihatan ? Ya.................................. Tidak.................................... Bila ya, jelaskan................................................................................................................ .......................................................................................................................................... 2. Berapa jauh gangguan tersebut ? Bagaimana ibu mengatasinya .......................................................................................... ........................................................................................................................................... ........................................................................................................................................... c. Pendengaran 1. Adakah gangguan pendengaran ? Ya........................................ Tidak............................... Bila ya, jelaskan................................................................................................................. ............................................................................................................................................ 2. Adakah menggunakan alat dengar ? Ya................................... Tidak..................................................................

3.Cairan 1) Apakah ada perubahan jumlah cairan yang diminum, selama kehamilan ? Meningkat................................ menurun................................................................... Tidak berubah............................................................................................................ 2) Minum apa yang disukai ? Air........................................ Kopi.......................................... Susu...................................... Teh........................................... Air Buah............................... lain-lain.................................... 3) Minuman apa yang tidak disukai ? ....................................................................................................................................

4. Nutrisi a. Gigi/mulut 1. Bagaimana keadaan gigi ibu ?................................. baik ............................................lubang.............................lain-lain 2. Apakah menggunakan gigi palsu ?................ ...ya..................tidak.........................atas ...........................bawah..................................sebagainya. 3. Apakah makanan ibu terbatas karena gigi ? Ya.............................. tidak........................... Bila ya, jelaskan................................................................................................................. .................................................................................................................................................

4. Adakah rasa sakit pada mulut ?.......................................................................... .............................. ya..........................................tidak............................................................ Bila ya, jelaskan................................................................................................................... .................................................................................................................................................

b. Apakah yang ibu ketahui tentang berat badan ibu ? .......................................................................................................................................................... ..........................................................................................................................................

c. Nafsu makan 1. Apakah kehamilan menimbulkan perubahan dalam cara makan ibu, Ya....... Tidak......... Bila ya, jelaskan................................................................................................................. ............................................................................................................................................ 2. Makanan utama.................................................................................................................. ........................................................................................................................................... 3. Adakah pantangan makan untuk ibu ? Ya... tidak...., bila ya makanan apa .................... dan mengapa....................................................................................................................... ..............................................................................................................................................

1. Diet a. Apakah ibu melakukan diet khusus ? Ya/tidak Bila ya, apa saja............................................................................................................... ………………………………………………………………………………………… b. Apakah ada masalah dengan diet tersebut? Ya....., tidak...... Bila ya, jelaskan.............................................................................................................. ...................................................................................................................................... c. Adakah resiko gangguan status nutrisi ? Ya......, tidak....... Bila ya, jelaskan.............................................................................................................. ........................................................................................................................................ ........................................................................................................................................

5. Eliminasi a. BAB 1. Dalam kehamilan ini adakah perubahantentang BAB ? Ya, tidak, bila ya jelaskan................................................................................................. ......................................................................................................................................... 2. Bagaimana biasanya : Obstipasi....................................................................................... Diare.............................................................................................. Tidak............................................................................................. 3. Berapa kali biasanya......................................................................................................... 4. Jam berapa biasanya........................................................................................................ 5. Apakah ibu menggunakan pencahar/klisma : Secara teratur................................................................................................................... Sering................................................................................................................................ Kalau perlu........................................................................................................................ Tidak pernah..................................................................................................................... 6. Apa yang dilakukan ibu untuk melancarkan BAB ? ya, atau tidak Bila ya, jelaskan................................................................................................................. ………………………………………………………………………………………… b. Kandung kemih 1. Adakah kesulitan pengeluaran air kemih, dalam kehamilan ? ya, tidak Bila ya, jelaskan................................................................................................................ .......................................................................................................................................... Bagaimana mengatasinya................................................................................................. ..........................................................................................................................................

6. Oksigen 1. Apakah kehamilan mengakibatkan perubahan dalam pernafasan ? ya, tidak....................... Bila ya, jelaskan.................................................................................................................... .............................................................................................................................................. Bagaimana menanganinya ?................................................................................................ ............................................................................................................................................. 7. Seksual 1. Apakah kehamilan menimbulkan perubahan sebagai istri ? ya, tidak, jelaskan.................. ............................................................................................................................................... ...............................................................................................................................................

2. Apakah kehamilan menimbulkan perubahan dalam hubungan suami-istri ? ya, tidak Bila ya , jelaskan................................................................................................................... ..............................................................................................................................................

V. RIWAYAT KEBIDANAN LALU

G............... P.................... A..........................

No

Gangg

Proses

Lama

Tempat

Masalah

Masal

Masal

Keadaan

Kel

uan

persalin

persali

penolong

persalinan

ah

ah

Anak

keham

an

nan

pers

nifas,

bayi

ilan

laktasi

* Tekanan darah meninggi; bengkak pada kedua tangan, muka, kaki, infeksi saluran perkemihan; perdarahan : premature ; lain-lain ** SC, sebab................................; perdarahan ; kejang-kejang ; lain-lain *** Perdarahan ; infeksi ; anemi ; lain-lain **** Pernafasan ; makanan ; icterus ; cacat ; meninggal dalam kandungan ; meninggal setelah lahir ; lain-lain ***** jenis hidup/mati (sebab kematian),.................................................................................

VI. Keluarga Berencana a. Jenis kontrasepsi apa yang pernah digunakan........................................................... b. Apakah ada masalah dengan cara tersebut ?............................................................. c. Jenis kontrasepsi yang direncanakan setelah persalinan sekarang ?......................... d. Berapa jumlah anak yang direncanakan oleh keluarga ?............................................

VII. Hasil Pemeriksaan BB sebelum hamil

: .........kg ; BB sekarang.............kg ; TB..............cm

Tekanan darah

:............................mmHg

Nadi

:..............x/menit

Edema

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

Lab : urin

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

Pemeriksaan Abdomen

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

Tinggi fundus

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

Taksiran kehamilan

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

Auskultasi

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

Ikhtisar pemeriksaan

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

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

VIII. Kesimpulan yang di dapat sebagai dasar dalam asuhan keperawatan............................ ................................................................................................................................................. .......................................................................................................................................................... .......................................................................................................................................................... ..................................................................................................................................

Lampiran 2 FORMAT PENGKAJIAN INTRANATAL Nama Mahasiswa :…………………………………. NIM :................................................ Tempat Praktek

:.................................... Tanggal :...........................................

1. DATA UMUM Inisial klien

:................................................. Nama Suami

;...............

Umur

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

Alamat

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

Pekerjaan

:................................................. Pendidikan terakhir :..............

Agama

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

Suku Bangsa

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

Status Perkawinan

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

Pendidikan terakhir

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

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

II. DATA UMUM KESEHATAN 1. TB/BB

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

2. Berat Badan sebelum hamil

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

3. Masalah kesehatan khusus

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

4. Obat-obatan

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

5. Alergi (obat/makanan/bahan tertentu) :............................................................................ 6. Diet khusus

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

7. Menggunakan

: gigi tiruan/kaca mata/lensa kontak/alat dengar)

8. Lain-lain sebutkan

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

9. Frekuensi BAK

:..............................kali/hari

Masalah 10. Frekuensi BAB Masalah 11. Kebiasaan waktu tidur

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

III. DATA UMUM OBSTETRI/KEBIDANAN 1. Kehamilan sekarang direncanakan (ya/tidak) :...................................................................

2.

Status obstetrikus : G.........P..........A............ Usia Kehamilan :...........................minggu

3.

HPHT :……………………………………… Taksiran Partus :…………………………

4. Jumlah anak di rumah :

No

Jenis Kelamin

Cara Lahir

BB lahir

Keadaan

Umur

1 2 3 4 5 6 7

5. Mengikuti kelas prenatal : (ya/tidak) 6. Jumlah kunjungan pada kehamilan ini :…………………………………………………. 7. Masalah kehamilan yang lalu :........................................................................................... 8. Masalah kehamilan sekarang :.......................................................................................... 9. Rencana KB

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

10. Makanan bayi sebelumnya : ASI/PASI/Lain-lain.......................................................... 11. Pelajaran apa yang diinginkan saat ini (lingkari) : relaksasi, pernapasan/manfaat ASI/cara memberi minum obat botol/senam nifas/metode KB/perawatan perineum/perawatan payudara 12. Estela bayi lahir, siapa yang diharapkan membantu : suami/teman/orangtua) 13. Masalah dalam persalinan yang lalu :…………………………………………………….

IV. RIWAYAT PERSALINAN SEKARANG 1. Mulai persalinan (kontraksi/pengeluaran pervaginam) : tgl/jam………………………… 2. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan ) :…………………… 3. Frekuensi dan kualitas denyut jantung janin :..................................................................... 4. Pemeriksaan fisik : Kenaikan BB selama kehamilan:............................................................................................ Tanda vital : TD............mmHg, Nadi.................x/mnt, P………….x/mnt, suhu............0C

Kepala dan leher (normal/tidak):............................................................................................... Jantung :.................................................................................................................................... ................................................................................................................................................. Paru-paru :.............................................................................................................................. ................................................................................................................................................. Payudara :............................................................................................................................... ................................................................................................................................................ .................................................................................................................................................

Abdomen (secara umum dan pemeriksaan obstetrik) :.......................................................... ................................................................................................................................................ Kontraksi :.....................................................DJJ :....................................................................

Ekstremitas: (edema/tidak)..................................................................................................... Refleks :................................................................................................................................... 5. Pemeriksaan dalam pertama: jam.................................oleh............................................... Hasil.................................................................................................................................................. .......................................................................................................................................................... ............................................................................................................................... 6. Ketuban (utuh/pecah), jika sudah pecah tgl/jam..............................warna........................ 7. Laboratorium :..................................................................................................................... .......................................................................................................................................................... ........................................................................................................................................

V. DATA PSIKOSOSIAL 1. Penghasilan keluarga setiap bulan : Rp............................................................................. 2. Bagaimana perasaan anda terhadap kehamilan sekarang.................................................. .......................................................................................................................................................... ........................................................................................................................................ 3. Bagaimana perasaan suami terhadap kehamilan sekarang................................................ .......................................................................................................................................................... .......................................................................................................................................................... ............................................................................................................................... 4. Jelaskan respon sibling terhadap kehamilan sekarang.......................................................

LAPORAN PERSALINAN

I. PENGKAJIAN AWAL 1. Tanggal :............................................................ Jam......................................................... 2. Tanda-tanda vital :TD...............mmHg, Nadi............x/mnt P...........x/mnt, suhu.............oC 3. Pemeriksaan palpasi abdomen :......................................................................................... 4. Hasil periksa dalam :........................................................................................................... 5. Persiapan perineum :........................................................................................................... 6. Dilakukan klisma : ya/tidak, jelaskan................................................................................... ................................................................................................................................................. 7. Pengeluaran pervaginam:.................................................................................................... 8. Perdarahan pervaginam : ya/tidak, jelaskan....................................................................... 9. Kontraksi uterus (frekuensi, lamanya, kekuatan) :............................................................. ................................................................................................................................................. 10.Denyut jantung janin (frekuensi, kualitas) :........................................................................ ................................................................................................................................................. 11. Status janin (hidup/tidak, jumlah, presentasi):.................................................................. .......................................................................................................................................................... .......................................................................................................................................................... ...............................................................................................................................

II. KALA PERSALINAN  KALA I 1. Mulai persalinan : tanggal................................................... jam......................................... 2. Tanda dan gejala :............................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... ............................................................................................................................... 3. Tanda-tanda vital : TD...............mmHg, Nadi............x/mnt P...........x/mnt, suhu............oC 4. Lama kala I : ....................jam...........................menit..................................detik 5. Keadaan psikososial :.......................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... ............................................................................................................................... 6. Kebutuhan khusus klien :....................................................................................................

.......................................................................................................................................................... .......................................................................................................................................................... ............................................................................................................................... 7. Tindakan :........................................................................................................................... .......................................................................................................................................................... ........................................................................................................................................ 8. Pengobatan :........................................................................................................................ .................................................................................................................................................

OBSERVASI KEMAJUAN PERSALINAN Tanggal/jam

Kontraksi uterus

DJJ

Keterangan

 KALA II 1. Kala II mulai : tanggal..................................................... jam............................................. 2. Lama Kala II :………………….Jam………………..menit…………………….detik 3. Tanda dan gejala :............................................................................................................... .......................................................................................................................................................... .......................................................................................................................................... 4. Jelaskan upaya meneran...................................................................................................... .......................................................................................................................................................... .......................................................................................................................................... 5. Keadaan psikososial............................................................................................................ .......................................................................................................................................................... ..........................................................................................................................................

6. Tindakan :............................................................................................................................ .......................................................................................................................................................... ..........................................................................................................................................

CATATAN KELAHIRAN 1. Bayi lahir jam :..................................................................................................................... 2. Nilai APGAR : menit I..............................................menit V............................................... 3. Perineum : (

) utuh, (

) episiotomi, (

) ruptur, tingkat...............................................

4. Bonding ibu dan bayi :......................................................................................................... 5. Tanda-tanda vital : Nadi............x/mnt, P.............x/mnt, suhu................0C 6. Pengobatan :........................................................................................................................ 

KALA III

1. Tanda dan gejala :............................................................................................................... .......................................................................................................................................................... ........................................................................................................................................ 2. Plasenta lahir jam :.............................................................................................................. 3. Cara lahir plasenta :............................................................................................................. .......................................................................................................................................................... ........................................................................................................................................ 4. Karakteristik plasenta : 

Ukuran...............cm x......................cm x...........................cm



Panjang tali pusat........................cm



Pembuluh darah............................arteri.......................vena



Kelainan.............................................................................................................................

5. Perdarahan :...................................ml, karakteristik :......................................................... ................................................................................................................................................. 6. Keadaan psikososial :.......................................................................................................... ................................................................................................................................................. ................................................................................................................................................. 7. Kebutuhan khusus klien :.................................................................................................... ................................................................................................................................................. 8. Tindakan :............................................................................................................................ .......................................................................................................................................................... ........................................................................................................................................ 9. Pengobatan :........................................................................................................................

 KALA IV 1. Mulai jam :............................................................................................................................ 2. Tanda-tanda vital : TD...............mmHg, Nadi............x/mnt P...........x/mnt, suhu............oC 3. Keadaan uterus :.................................................................................................................. .......................................................................................................................................................... ........................................................................................................................................ 4. Perdarahan :.............................................................. Karakteristik..................................... .......................................................................................................................................................... ........................................................................................................................................ 5. Bonding ibu dan bayi :........................................................................................................ .......................................................................................................................................................... .......................................................................................................................................... 6. Tindakan :............................................................................................................................ ................................................................................................................................................

LAPORAN PARTUS NORMAL ”SYAIR OBSTETRI”

Inisial Ibu

:

Status Obstetrikus

:

Tanggal/Jam

Keterangan

FORMAT PENGKAJIAN BAYI BARU LAHIR

Nama Mahasiswa :......................................... Rumah Sakit :.................................................. Nama Ayah-Ibu :.......................................... Tanggal Pengkajian :........................................ Alamat

:.......................................... Jam Pengkajian :..............................................

RIWAYAT KELAHIRAN YANG LALU No

Tahun

Sex

BB Lahir

Keadaan

kelahiran

Komplikasi

bayi

Jenis

Ket

Persalinan

1 2 3 4 5 6 7

STATUS GRAVIDA G.......... P..............A............. H................

Presentasi bayi.............................................

Pemeriksaan antenatal: teratur/tidak teratur Komplikasi antenatal :............................................

RIWAYAT PERSALINAN BB/TB Ibu :............Kg/.................cm

Persalinan di........................................................

Keadaan umum ibu.................................... Tanda vital............................................................ Jenis persalinan :....................................... Proses persalinan : Kala I...............................jam Indikasi :.................................................. Kala II............................menit Komplikasi persalinan : Ibu.......................................... fetus................................................... Lamanya ketuban pecah..............................................Kondisi ketuban................................... KEADAAN BAYI SAAT LAHIR Lahir tanggal :………………………… jam…………………….. sex…………………….. Kelahiran : Tunggal/Gemelli)

NILAI APGAR Tanda

0

1

2

Jumlah

Frekuensi

( ) O Tidak ada

( ) O < 100

( ) O > 100

jantung

( ) O Tidak ada

( ) O Lambat

( ) O Menangis

Usaha Napas

kuat ( ) O Lumpuh

( ) O Extremitas

Tonos otot

( ) O Gerakan

fleksi sedikit

( ) O Tidak Refleks

bereaksi

aktif

( ) O Gerakan sedikit

( ) O Reaksi

( ) O Biru/pucat Warna kulit

melawan ( ) O Tubuh

( ) O Kemerahan

kemerahan tangan dan kaki biru Ket : ( ) Penilaian menit -1

O Penilaian menit ke 5

Tindakan resusitasi................................................................................................................... Plasenta : Berat....................................... Tali pusat : Panjang................................................. Ukuran..................................... Jumlah pemb.darah............................... Kelainan................................... Kelainan................................................

PENGKAJIAN FISIK Umur :.................... Hari........................... jam Berat Badan.........................................gram Panjang Badan..................................... cm 0

Perut

( ) Lembek ( ) Kembung

Suhu....................................................... C

( ) Benjolan

Lingkar Kepala........................cm

Bising

Lingkar dada........................... cm

usus...............x/menit

Lingkar perut........................... cm

Lanugo...................................................

KEPALA

Vernix....................................................

Bentuk

( ) Bulat

Mekonium.............................................

( ) Lain-lain Kepala

( ) Molding

PUNGGUNG

( ) Kaput

Keadaan punggung

( ) Cephalhematom

(

) Asimetris

Ubun-ubun

( ) Pilonidal

Besar……………………………..

dimple

Kecil………………………………

Fleksibilitas

Sutura..................................

Tul.punggung

Posisi.............................................. Mata

(

) Kotoran

(

) Perdarahan

Telinga

Posisi...................................... Bentuk....................................

Mulut

Hidung

Leher

(

) Lubang telinga

(

) Keluaran

(

) Simetris

(

) Palatum mole

(

) Palatum durum

(

) Gigi

(

) Lubang hidung

(

) Keluaran

(

) Pernapasan cuping hidung

(

) Pergerakan leher

(

) Pink

(

) Pucat

(

) Sianosis

(

) Kuning/Ikterus

(

) Aktif

(

) Kurang

(

) Asimetris

(

) Retraksi

(

) Seesaw

TUBUH Warna

Pergerakan

Dada

Jantung & Paru Bunyi napas

(

) Ngorok

(

) Lain-lain......................... ..

GENITALIA

(

) Kelainan

Pernapasan...................x/menit Denyut jantung......................x/menit

FORMAT PENGKAJIAN POST NATAL Nama Mahasiswa

: ……………………..

Ruangan/RS……………………………

Tanggal Pengkajian :……………………….

DATA UMUM KESEHATAN 1. Inisial Pasien :…………………………

Usia :………………………………….

2. Status Obstetrikus: NH………P……..A……… No

Tipe Persalinan

BB Waktu

Keadaan Bayi

Umur

Lahir

Waktu Lahir

sekarang

1

2

3

4

5 3. Masalah prenatal :………………………………………………………………… 4. Riwayat persalinan sekarang……………………………………………………… 5. Riwayat KB………………………………………………………………………. 6. Rencana KB……………………………………………………………………….

DATA POSTNATAL 1. Payudara  Kesan umum :………………………………………………………………  Putting susu :……………………………………………………………….

2. Diastasis Rectus abdominis  Ukuran:…………………………………………………………………….. 3. Fundus Uterus 

Tinggi :…………………………………………………………………….



Posisi :…………………………………………………………………….



Kontraksi :…………………………………………………………………

4. Lochia 

Jumlah :…………………………………………………………………….



Warna :……………………………………………………………………..



Konsistensi :………………………………………………………………..



Bau :………………………………………………………………………..

5. Perineum 

Utuh, Episiotomi, Ruptur :………………………………………………………. ………………………………………………………………………………… REEDA Sign

:………………………………………………………..

………………………………………………………………………………… 

Keadaan

: ………………………………………………………

………………………………………………………………………………………. 

Kebersihan

:………………………………………………………..

………………………………………………………………………………………. 6. Hemoroid :…………………………………………………………………………… ………………………………………………………………………………………. 7. Varises

:…………………………………………………………………………….

…................................................................................................................................. 8. Homan’s Sign :……………………………………………………………………….. ………………………………………………………………………………………. 9. Kebiasaan BAK :……………………………………………………………………. ………………………………………………………………………………………. ………………………………………………………………………………………. 10. Kebiasaan BAB………………………………………………………………………. ……………………………………………………………………………………….…… ………………………………………………………………………………… 11. Pola Tidur :…………………………………………………………………………… ……………………………………………………………………………………….…… …………………………………………………………………………………

12. Keadaan Mental :……………………………………………………………………. ………………………………………………………………………………………. ……………………………………………………………………………………….. 13. Asupan nutrisi :………………………………………………………………………. ………………………………………………………………………………………. ………………………………………………………………………………………. 14. Penyesuaian dengan bayi :…………………………………………………………… ………………………………………………………………………………………. 15. Rangkuman :………………………………………………………………………… ………………………………………………………………………………………..… …………………………………………………………………………………… ……………………………………………………………………………………….

1. ANALISA DATA No

DATA

MASALAH KEPERAWATAN

ETIOLOGI

2. DIAGNOSA KEPERAWATAN 1) …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ………………………………………………………………… 2) …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ………………………………………………………………… 3) …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… ……………………………………………………………………… 4) …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………………

FORMAT EVALUASI KEPERAWATAN MATERNITAS

Nama

:……………………………………….

NIM

:…………………………………….....

Pembimbing

:………………………………………

Rumah Sakit

:………………………………….

No

Aspek Penilaian

Nilai Maksimal

1.

Pengkajian (gunakan format sesuai dengan kasus klien yang diambil ):

20

 Mengumpulkan data subjektif dan objektif yang meliputi data fisik dan psikososial  Mengidentifikasi masalah berdasarkan data  Merumuskan diagnose keperawatan dengan benar untuk setiap kali persalinan  Menetapkan prioritas. 2.

Perencanaan

30

 Menuliskan rencana keperawatan dengan jelas serta dapat diukur.  Menetapkan Tum dan Tuk.  Menetapkan criteria evaluasi.  Menuliskan rasional tindakan keperawatan.  Menetapkan prioritas tindakan keperawatan  Menetapkan dan menguraikan tindakan sesuai diagnose 3.

Pelaksanaan

25

 Menggunakan instrument yang tepat  Memberikan pendidikan kesehatan  Memberikan asuhan konsisten dengan masalah klien  Melakukan kolaborasi denganp rofesi lain  Menuliskan catatan keperawatan dan pelaporan secara sistematis. 4.

Evaluasi.

25

 Memperhatikan dengan baik terhadap perubahan yang ada  Mampu mengidentifikasi / memodifikasi tindakan yang diperlukan .  Menetapkan keberhasila askep melalui evaluasi secara subjektif dan objektif.  Menganalisa hasil evaluasi  Membuat perencanaan selanjutnya terhadap klien Jumlah

100

Nilai

Keterangan : Penilaian ≤ 56 : Kurang 56 – 67 : Cukup 68 – 80 : Baik 81 – 100 : Baik sekali