ASUHAN KEPERWATAN PADA ..

DENGAN
DI RUANG.

TANGGAL PENGKAJIAN :
A. PENGKAJIAN
1. IDENTITAS
a. Identitas klien
Nama

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

Umur

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

Jenis Kelamin

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

Pekerjaan

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

Alamat

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

Pendidikan

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

Agama

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

Suku bangsa

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

Tanggal Masuk RS

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

No. CM

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

Dx Medis

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

Tanggal Pengkajian

b. Identitas Penanggung Jawab

Nama

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

Umur

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

Jenis Kelamin

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

Pekerjaan

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

Alamat

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

Pendidikan

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

Agama

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

Hubungan dengan Klien : ............................................................................................................

STIKes Karsa Husada Garut

2. RIWAYAT KESEHATAN
a. Keluhan Utama
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b. Riwayat Kesehatan Sekarang
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c. Riwayat Kesehatan Dahulu
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d. Riwayat Kesehatan Keluarga
1. Riwayat penyakit menurun/ menular
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2. Genogram

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e. Riwayat Alergi
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3. RIWAYAT PERSALINAN DAN KELAHIRAN YANG LALU

NO. Tahun

Tipe
persalinan

Penolong

Pengalaman menyusui : ya/ tidak

Jenis

BB

Keadaan

Masalah post

kelamin

lahir

kesehatan

partum

berapa lama :

Jika tidak, apa alasannya :.

4. Riwayat Ginekologi
a. Riwayat menstruasi
Menarche

Siklus

Lama dan jumlah darah/ volume/ ganti pembalut

hari

b. Riwayat KB
Jenis

Lama menggunakan

Keluhan

c. Riwayat ginekologi

5. Data umum kehamilan

a. Kehamilan sekarang direncankan

: (ya/ tidak)

b. Status obstetric

: G P.. A usia kehamilan: .minggu

c. HPHT

: .. taksiran partus :

..
d. Mengikuti kelas prenatal

: ya/ tidak

e. Kunjungan ANCke

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f. Masalah kehamilan sekarang

g. Rencana KB

:
:

h. Pengetahuan apa yang diinginkan saat ini

: (lingkari) relaksasi, pernafasan/ manfaat asi/

senam nifas/ metode KB/ perawatan perineum/ perawatan payudara.

i. Pendamping saat persalinan

: suami/ teman/ orang tua/ tidak dengan pedamping

j. Masalah dalam persalinan yang lalu :

6. POLA KESEHATAN FUNGSIONAL
a. Pemeliharaan kesehatan
........................................................................................................................................................
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b. Nutrisi Metabolik
No
1

Jenis

sehat

sakit

Sebelumt dirawa

Selama dirawat

Pola makan
Jenis
Porsi
Frekuensi
Diet khusus
Makanan disukai
Kesulitan menelan
Gigi palsu
Napsu makan
Pola minum
Jenis
Frekuensi
Jumlah
Pantangan
Minuman yang disukai

c. Pola eliminasi
No
1

Jenis
BAB
Frekuensi
Warna
Masalah
2
BAK
Frekuensi
Jumlah
Warna
Masalah
d. Pola aktivitas sehari hari

STIKes Karsa Husada Garut

Sehat

No

Jenis

1
2
3
4
5
6
7
8
9
10

Mandi
Berpakaian
Eliminasi
Mobilisasi di tempat tidur
Berpindah
Berjalan
Berbelanja
Memasak
Naik tangga
Pemeliharaan rumah

Selama dirawat
3

Ket:
0 : Mandiri
1 : Alat bantu
2 : Dibantu orang lain
3 : dibantu orang lain alat
4 : tergantung / tidak mampu

e. Pola persepsi kognitif

Berbicara

: .........................................................................................................
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Bahasa

: .........................................................................................................
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Kemampuan membaca

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

Kemampuan berinteraksi : .........................................................................................................

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f. Pola istirahat / tidur
No
1

Jenis

Sebelumt dirawat

Selama dirawat

Tidur siang
Lama tidur
Keluhan
Tidur malam
Lama tidur
Keluhan

g. Pola konsep diri

Ideal diri

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

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.........................................................................................................
Harga diri

: .........................................................................................................
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Identitas diri

: .........................................................................................................
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Peran diri

: .........................................................................................................
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h. Pola peran dan Hubungan

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i. Pola Reproduksi dan Seksual
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j. Pola pertahanan diri atau koping
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k. Pola keyakinan dan nilai
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7. PEMERIKSAAN FISIK IBU
1. Keadaan Umum
:
Kesadaran
:
2. TTV
: TD :

R:

GCS:
N:

E:
S:

V:

BB/ TB :
M:

3. KEPALA
a. Inspeksi dan palpasi kepala
1) Bentuk dan kesimetrisan :
2) Lesi/ luka, bersih
:
b. Inspeksi dan palpasi rambut
1) Warna
:
2) Tekstur
:
3) Penyebaran :
4) Kebersihan :
c. Pemeriksaan muka :
1) Inspeksi
( warna kulit dan kesimetrrisan)
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2) Gerakan muka : simetris/ tidak

3) Tes sensai wajah :
d. Pemeriksaan mata
1) Ketajaman penglihatan :
2) Inspeksi dan palpasi struktur mata eksternal
i. Posisi mata
:
ii. Kelopak mata
:
Karakter kulit
: kemerahan/ tidak
Oedema: ada/ tidak
Lesi/ cacat : ada/ tidak ada
iii. Bola mata
Posisi :
Penonjolan :
iv. Konjungtiva :
Warna merah : muda/ anemis
Kebersihan : bersih/ kotor, ada eritema/ tidak
v. Pupil/ iris : warna hitam, bundar, teratur, ukuran sebanding atau tidak,
miosis, middriasis
vi. Sclera warna :..
e. Pemeriksaan telinga
Posisi
:
Warna
:
Tekstur
:
Kebersihan
:
Pola pendengaran
:
f. Hidung dan sinus
Posisi
:
Warna
:
Tekstur
:
Kebersihan
:
Ketajaman penciuman
:
Bau nafas
:
4. Mulut dan tenggorokan
a. Bibir
Warna
Tekstur
Mukosa
Kondisi

:
:
:
:

b. Gigi
Jumlah
Warna

:
:
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c.

d.

e.
f.
g.
h.

Kondisi
Lidah
Warna
Tekstur
Mukosa
Kondisi
Pergerakan
Fungsi lidah
Reflek menelan
Keluhan
Gusi
Warna
Keluhan
Inspeksi palatum dan uvula
Inspeksi tonsil
Inspeksi faringeal
Tes rasa

:
:
:
:
:
:
:
:
:
:
:
:
:
:
: mengecap rasa

5. Pemeriksaan leher
a. Leher : hiperekstensi/ tidak, ada masa/ tidak
b. Pembesaran kelenjar tyroid : ada/ tidak
c. JVP
:
6. Pemeriksaan dada
a. Thoraks
i. Inspeksi
1. Pernafasan : dada/ perut frekuensi :
2. Kontur dada: simetris/ tidak
3. Klavikula
:
sternum :
4. Spina :
scapula:
ii. Palpasi
1. Nyeri atau tidak
2. Tulang vertebrae spina : kaku/ tidak
3. Lengkung iga : lentur/ tidak
4. Gerak dada: simetris/ tidak
5. Taktil fremitus : simetris/tidak
6. Fibrasi : lemah/ tidak
iii. Perkusi thoraks
1. Thoraks posterior
: resonan, hipersonan, tymfani
iv. Auskultasi
1. Trachea, bronchus : (vesikuler, bronchial, tracheal)
2. Bunyi napas tambahan : (rales ronchi, wheezing, friksi pleura)
b. Dada
i. Jantung
Bunyi
:
Irama
:
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Frekuensi
ii. Payudara
Inspeksi
Palpasi

:
:
:

7. Abdomen
a. Inspeksi
b. Kesimetrisan :
c. Warna kulit :
d. Lesi:
e. Striae :
f. Linea :
g. Leopold I:
h. Leopold II:
i. Leopold III:
j. Leopold IV:
k. TFU:
l. Bising usus :
m. Hepar : nyeri/ tidak
n. Limpa
o. Ginjal kanan kiri : nyeri/ tidak
8. Genitalia
a. Hematoma : ada/ tidak ada
b. Bengkak
: ada/ tidak ada
c. Perdarahan : ada/ tidak ada
d. Varises
: ada/ tidak ada
9. Anus
a. Hemoroid : ada/ tidak ada
10. Ekstremitas
i. Ekstremitas Atas
Bentuk
:
Pergerakan
:
Refleks
:
Keadaan
:
Edema
:
Turgor
:
Kekuatan otot

j. Ekstremitas Bawah
k. Bentuk
l. Pergerakan

:
:
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m.
n.
o.
p.
q.
r.

Refleks
Keadaan
Edema
Turgor

:
:
:
:

Kekuatan otot

8. PEMERIKSAAN PENUNJANG
No Lab
Nama
Umur
Alamat
No
1

:
:
:
:

Nama Test
Hematologi
Darah Rutin
Hemoglobin
Hematokrit
Leukosit
Trombosit
Eritrosit
Laju Endap Darah
Morfologi darah tepi
Eritrosit
Leukosit
Trombosit
Kesan
Kimia Klinik
AST/SGOT
ALT/SGPT
Ureum
Kreatinin
Protein total
Albumin
Glukosa sewaktu
Glukosa puasa
Kolesterol total
Natrium
Kalium
Imunologi
HbsAg
Anti Dengue Igg
Anti Dengue IgM

No Cm
Ruangan
Jenis Kelamin
Tanggal
Hasil

:
:
:
:

Unit

Nilai Normal

g/dL
%
/mm3
/mm3
juta/mm3
/mm3

13.0-18.0
40-52
3.800-10.000
150.000-440.000
3.5-6.5

u/L
u/L
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL

s/d 37
40
15-50
15-50
0.7-1.2
6.6-8.7
3.5-5
<140
70-110
135-145
3.6-5.5

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9.

Widal
Lainnya

TERAPI :

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B. ANALISA DATA
No

Data

Etiologi

Problem

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No

Data

Etiologi

Problem

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C. DIAGNOSA KEPERAWATAN
1.

2.

3.

4.

5.

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D. NURSING CARE PLAN

Diagnosa Keperawatan/ Masalah

Kolaborasi

Rencana keperawatan
Tujuan dan Kriteria Hasil

Intervensi

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D. IMPLEMENTASI
Tgl/Jam

No DP

Implementasi

Evaluasi

Paraf

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F. EVALUASI
Tgl/Jam

No DP

Evaluasi
.......................................................................................

Paraf

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G. CATATAN PERKEMBANGAN

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No

Tanggal

Dp

Catatan Perkembangan
....................................................................................

Pelaksana

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