YAYASAN PENDIDIKAN SETIH – SETIO

AKADEMI KEPERAWATAN SETIH – SETIO MUARA BUNGO

Jalan S. Hasanuddin No. Telp : ( 0747 ) 22153 Kode Pos : 37214
MUARA BUNGO

ASUHAN KEPERAWATAN PADA IBU DENGAN KONTRASEPSI

1. DATA SUBJEKTIF
A. BIODATA

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

Um ur :............................................. Umur :....................................................

Pendidikan :............................................. Pendidikan :....................................................

Agama :............................................. Agama :....................................................

Suku Bangsa:............................................. Suku Bangsa :....................................................

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

Alamat :............................................. Alamat :...................................................

T T L :............................................. TTL :....................................................
Jam :............................................. Jam :....................................................

B. KELUHAN UTAMA :.....................................................................................................................

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

C. RIWAYAT KESEHATAN YANG LALU

Ibu Pernah menderita penyakit :
 Jantung :....................................
 Paru – paru :....................................
DM :....................................
 Thyroid :....................................
 Examna :....................................
 Hypertensi :....................................
 Dekomp Cordis :....................................................
 Hepatitis :....................................................
 Ca. Mamae :....................................................
 Ca. Reproduksi :....................................................
 Alergi thd logam :....................................................
 Sakit kepal hebat :....................................................

D. RIWAYAT KESEHATAN SEKARANG

 Jantung :..............................................
DM :..............................................
 Paru – paru :..............................................
 Thyroid :..............................................
 Examna :..............................................
 Hypertensi :..............................................

E. RIWAYAT MENYUSUI SAAT INI

 Menyusui / Tidak :.....................................................................................
 Rencana anak disapih pada usia :.....................................................................................

F. RIWAYAT KONTRASEPSI YANG LALU

 Jenis kontrasepsi yang digunakan :.....................................................................................
G. RIWAYAT OBSTETRI
 Siklus Haid :............................. Hari  Warna :...............................................................
 Lama Haid :............................. Hari  Bau :...............................................................
 Banyaknya :.............................. X Ganti Softek
 Pendarahan Persalinan :................................................................................................
 Pendarahan diluar Haid :................................................................................................
 Haid terlalu lama / Berlebihan :................................................................................................
 Jumlah anak :............................................................................. Orang
 Anak laki – laki :.............................................................................
 Anak Perempuan :.............................................................................
 H. RIWAYAT PENGGUNAAN KONTRASEPSI
Yang Lalu :................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Yang Dipakai Sekarang :..........................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

I. KEADAAN PSIKOSOSIAL
........................................................................................................................................................
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2. DATA OBYEKTIF

PEMERIKSAAN FISIK

a. Keadaan Umum:.....................................................................................................................
......................................................................................................................

b. Tanda Vital : Suhu :.................. C TB :....................................................

Nadi :.................. X/m BB :....................................................
Respirasi :................... X/m

c. Mata : Sclera :............................................

Conjungtiva :............................................
Clhoasma Gravidarum :..........................................................................

d. Leher : Kelenjar Tiroid :..........................................................................

Vena Jugolaris :..........................................................................

e. Mamae : Pembesaran :.....................................................................................

Benjolan :.....................................................................................
Getah abnormal dari puting susu :..............................................................

g. Dada : 1. Jantung :...............................................................

2. Kelainan jantung :...............................................................
3. Rasa sakit hebat di dada :...............................................................
4. Paru – paru :...............................................................
 Kelainan Paru – paru :...............................................................
 Nafas sesak hebat di dada :...............................................................

h. Abdomen : Hepar membesar / tidak Iya Tidak

Hepar nyeri tekan / tidak Iya Tidak
Palpasi :
 Pembesaran Uterus :.....................................................................................
 Tumor :.....................................................................................

i. Genitalia Externa :.................................... Varises :...............................................................

Flour albus :..........................................................
Bau :...............................................................
Gatal :...............................................................

j. Genitalia interna :......................................................

 Posisi uterus :......................................................
 :......................................................
 :......................................................
 k. Laboratorium
 Urine : Albumin :..........................................................................................................
Reduksi :..........................................................................................................
Plasenta :..........................................................................................................

 Darah : HB :................................................................................................. gr %
Gol. Darah :..........................................................................................................
 Secret Vagina :..........................................................................................................
 Pap Smear :..........................................................................................................

l. Extremitas
 Atas :................................................................................................................................
 Bawah : Oedema :..........................................................................................................
Varises :..........................................................................................................
Rasa sakit hebat pada betis :..........................................................................

m. Pemeriksaan Diagnostik
 Pemeriksaan USG :..........................................................................................................
 Pemeriksaan RO :..........................................................................................................

n. Pengobatan Theraphy :..........................................................................................................

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3. ANALISA DATA

1.

2.

3.

4.

5.

4. DIAGNOSA DAFTAR MASALAH

1.

2.

3.

4.

5.

.............................................................. 200

Yang Melakukan Pengkajian

.........................................................
 NIM:

ANALISA DATA

NO DATA PENYEBAB MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :...................................................

NO REGISTER :...................................................

TANGGAL PARAF NO DIAGNOSA KEPERAWATAN TANGGAL PARAF

MUNCUL TERATASI PERAWAT

C A T A T A N PERKEMBANGAN

NAMA PASIEN :...........................................................................

NO REGISTER :...........................................................................
TANGGAL :...........................................................................

tgl/ diagnosa keperawatan catatan perkembangan paraf

bulan/jam (soapier)

C A T A T A N KEPERAWATAN

NAMA PASIEN :...........................................................................

NO REGISTER :...........................................................................
TANGGAL :...........................................................................

NO TANGGAL WAKTU CATATAN PERAWAT PARAF