ASUHAN KEPERAWATAN PADA Ny

DENGAN
DI RUANG
RS
TANGGAL .

I.

PENGKAJIAN
A.

IDENTITAS PASIEN
Penanggung Jawab
Nama

Nama

Umur

Umur

Pendidikan

Pendidikan

Pekerjaan

Jenis kelamin :

Status Perkawinan

Pekerjaan

Agama

Alamat

Suku

Status perkawinan :

Alamat

No CM

Tanggal MRS

Tanggal Pengkajian

Sumber informasi

Agama

B.

DATA KESEHATAN
1.

Keluhan Utama

2.

Keluhan saat dikaji

3.

Riwayat keluhan (kaji data mulai dari

timbulnya keluhan sampai dengan dilakukan asuhan keperawatan)

C. RIWAYAT OBSTETRI DAN GINEKOLOGI

1.Riwayat Menstruarsi :
a. Menarche : umur ..

Siklus :

teratur ( ) tidak ( )

b. Banyaknya :.

Lama :

c. Keluhan :
d. HPHT :..
2. Riwayat pernikahan
Menikah : .kali

Lama : .tahun

3. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak Ke
Kehamilan
N Th Umur
Penyuli
o

kehamila

jeni

Persalinan
penolon Penyuli

Komplikasi nifas
Laseras infeks Perdaraha

Anak
Jenis
B

Kelami

4. Riwayat kehamilan saat ini

Status Obstetrikus :
a.

GPAH

UK :

..minggu
b.

TP

: .

c.

ANC kehamilan sekarang :..

Trimester I :

Trimester II :

Pj

Trimester III :

5. Riwayat keluarga berencana

a.

Akseptor KB

: ... Jenis:

Lama:
b.

Masalah

D. RIWAYAT PENYAKIT
1.

Klien

2.

Keluarga

E. POLA FUNGSIONAL KESEHATAN

1. Pola Manajemen Kesehatan-Persepsi Kesehatan

2. Pola Metabolik-Nutrisi

3. Pola Eleminasi

4. Pola Aktivitas-Latihan

5. Pola Istirahat-Tidur

6. Pola Persepsi-Kognitif

7. Pola Konsep Diri-Persepsi Diri

8. Pola Hubungan-Peran

9. Pola Reproduktif-Seksualitas

10. Pola Toleransi Terhadap Stres-Koping

11. Pola Keyakinan-Nilai

F. PEMERIKSAAN FISIK
Keadaan umum :
1. GCS

:..

2. Tingkat kesadaran

: .

3. Tanda tanda vital

: TD.. ...........N.........RR.........T.......

4. BB

: .TB: LILA :..

Head toe toe :

a. Kepala
Wajah :...........................................................................

Pucat
( )
Cloasma
( )
Sklera :...........................................................................
Konjungtiva :...................................................................
Pembesaran limphe node :.............................................
Pembesaran kelenjar tiroid :............................................
Telinga

b. Dada
Payudara
Areola :..

Putting : (menonjol / tidak )

Tanda dimpling / retraksi

:.

Pengeluaran ASI

: ..

Jantung

: .

Paru: ..

c. Abdomen
Linea :

Striae :

Pembesaran sesuai UK : .
Gerakan Janin

: ..

Kontraksi : .

Luka bekas operasi : ..

Ballottement : ..
Leopold I

: Kepala / bokong / kosong

Leopold II

: Kanan : punggung/bagian kecil/bokong /kepala

Kiri

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

: punggung / bagian kecil /bokong/kepala

Leopold III : Presentasi kepala / bokong/kosong

Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar)
Penurunan kepala : .........(penurunan bag.terbawah dengan metode
lima jari)

Kontraksi

: .

DJJ

:..

Bising usus : ..

d. Genetalia dan perineum :

Kebersihan

Pengeluaran :.

Karakteristik :..

Hasil VT :

Hemoroid

e. Ekstremitas
Atas :
Oedema

Varises

CRT

Bawah :
Oedema

Varises

CRT

Refleks

:....

G. DATA PENUNJANG
1. Pemeriksaan Laboratorium

2. Pemeriksaan USG

H. DIAGNOSA MEDIS

.........................................................................................................................
......................................................................................................................
I. PENGOBATAN
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
......................................................................................................................
II. ANALISA DATA KALA I
DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

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

III. RENCANA KEPERAWATAN KALA I

No

Tgl / jam

Nomor
Diagnosa

Tujuan

Rencana Keperawatan
Intervensi

Rasional

IV. IMPLEMENTASI KALA I

Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

V. EVALUASI KALA I
Tgl/Jam

No Dx

Evaluasi Hasil

Paraf

KALA II
A. DATA FOKUS KALA II
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
......................................................................................................................................
B. ANALISA DATA KALA II
DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

C. RENCANA KEPERAWATAN KALA II

No

Tgl / jam

Nomor
Diagnosa

Tujuan

Rencana Keperawatan
Intervensi

Rasional

D. IMPLEMENTASI KALA II
Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

E. EVALUASI KALA II
Tgl/Jam

No Dx

Evaluasi Hasil

Paraf

KALA III
A. DATA FOKUS KALA III
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
B. ANALISA DATA KALA III
DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

C. RENCANA KEPERAWATAN KALA III

No

Tgl / jam

Nomor
Diagnosa

Tujuan

Rencana Keperawatan
Intervensi

Rasional

D. IMPLEMENTASI KALA III

Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

E. EVALUASI KALA III

Tgl/Jam

KALA IV

No Dx

Evaluasi Hasil

Paraf

A. DATA FOKUS KALA IV

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

B. ANALISA DATA KALA IV

DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

.
C.
No

RENCANA KEPERAWATAN KALA IV

Tgl / jam

Nomor
Diagnosa

Tujuan

Rencana Keperawatan
Intervensi

Rasional

D. IMPLEMENTASI KALA IV
Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

E. EVALUASI KALA IV
Tgl/Jam

No Dx

Evaluasi Hasil

Paraf

Denpasar, .20..

Mengetahui
Pembimbing Klinik/ CI

Mahasiswa

(.)

(.)

NIP:

NIM:

Clinical Teacher/CT

(.. )
NIP: