FORMAT ASUHAN KEPERAWATAN MATERNITAS

“ANTENATAL”

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 : Agama :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
B. ALASAN KUNJUNGAN
a. Keluhan Utama/Alasan ke Poliklinik
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 b. Keluhan saat dikaji (jika ada)

C. RIWAYAT OBSTETRI DAN GINEKOLOGI

a. Riwayat Menstruarsi :
1. Menarche : umur ….. Siklus : teratur ( ) tidak ( )
2. Banyaknya : Lama :………
3. Keluhan :
4. HPHT :
b. Riwayat pernikahan
Menikah : …. kali Lama : …. tahun
c. Riwayat kehamilan, persalinan, nifas yang lalu :
Anak Ke Kehamilan Persalinan Komplikasi nifas Anak
No Th Umur Peny jenis peno Peny laser Infe Perda Jenis BB Pj
kehamilan ulit long ulit asi ksi rahan Kelamin

d. Riwayat kehamilan saat ini

Status Obstetrikus :
1. G…A…P…A…H… UK : ……..minggu
2. TP : ….
3. ANC kehamilan sekarang :………..
 e. Riwayat keluarga berencana
1. Akseptor KB : …... Jenis :…… Lama :………
2. Masalah : ……
D. RIWAYAT PENYAKIT
1. Klien :…………

2. Keluarga : …………

E. POLA KEBUTUHAN SEHARI-HARI

1. Bernafas

2. Nutrisi (makan/minum)

3. Eliminasi

4. Gerak Badan

5. Istrirahat tidur

6. Berpakaian

7. Rasa Nyaman

8. Kebersihan Diri

9. Rasa Aman
 10. Pola Komunikasi/Hubungan Dengan Orang Lain

11. Ibadah

12. Produktivitas

13. Rekreasi

14. Kebutuhan belajar

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 :
1. Kepala
a. Wajah :
b. Pucat ( )
c. Cloasma ( )
d. sklera :
e. konjungtiva :
f. pembesaran limphe node :
g. pembesaran kelenjar tiroid :
h. telinga : ………………………………………

2. Dada
a. Payudara :
 b. Areola :…………….. Putting : (menonjol / tidak )
c. Tanda dimpling / retraksi :………………….
d. Pengeluaran ASI : ………………..
e. Jantung : ………. Paru: …………..
3. Abdomen
Linea : ……… Striae :…………
a. Pembesaran sesuai UK : ………….
b. Gerakan Janin : ………….. Kontraksi : …….
c. Luka bekas operasi : …………..
d. Ballottement : ………………………..
e. Leopold I : Kepala / bokong / kosong TFU:…….............
f. Leopold II : Kanan : punggung/ bagian kecil/ bokong / kepala
i. Kiri : punggung / bagian kecil /bokong/kepala
g. Leopold III : Presentasi kepala / bokong/kosong
h. Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar)
i. Penurunan kepala : ................(penurunan bag.terbawah dengan metode lima jari )
j. Kontraksi : ………………….
k. DJJ :………………….. Bising usus ………………
4. Genetalia dan perineum :
a. Kebersihan :………………
b. Keputihan :…………………. Karakteristik :……………..
c. Hemoroid :…………………
5. Ekstremitas
a. Atas :
Oedema :…………………
Varises :…………………
CRT :…………………
b. Bawah :
Oedema :…………………
 Varises :…………………
CRT :…………………
Refleks :………………....
G. DATA PENUNJANG
a. Pemeriksaan Laboratorium
 b. Pemeriksaan USG:
………………………......................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
H. DIAGNOSA MEDIS
................................................................................................................................................
................................................................................................................................................
I. PENGOBATAN
................................................................................................................................................
................................................................................................................................................
II. ANALISA DATA

DATA ETIOLOGI MASALAH

 Diagnosa keperawatan berdasarkan prioritas :
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

III. RENCANA KEPERAWATAN

No Tgl/jam Diagnosa Rencana Keperawatan

Tujuan Intervensi Rasional
IV. IMPLEMENTASI

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

V. EVALUASI

Tgl/Jam No Dx Evaluasi Hasil

 Denpasar, …………………….20…..
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(……………………….) (………………………….)
NIP: NIM:

Clinical Teacher/CT

(……..……………… )
NIP
 FORMAT ASUHAN KEPERAWATAN MATERNITAS
“ INTRANATAL “

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 : Agama :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
B. DATA KESEHATAN
a. Keluhan Utama

b. Keluhan saat dikaji :………………

 c. 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 Persalinan Komplikasi nifas Anak
No Thn Umur Peny jenis Penolo Pen La infe Perd Jenis BB Pj
keha ulit ng yuli ser ksi arah Kelami
milan t asi an n

4. Riwayat kehamilan saat ini

 Status Obstetrikus :
a. G…A…P…A…H… UK : ……..minggu
b. TP : ….
c. ANC kehamilan sekarang :………..
Trimester I :

Trimester II :

Trimester III :

5. Riwayat keluarga berencana

 a. Akseptor KB : …... Jenis:…… Lama:………
b. Masalah : ……

D. RIWAYAT PENYAKIT
1. Klien :…………

2. Keluarga : …………

E. POLA KEBUTUHAN SEHARI-HARI

1. Bernafas

2. Nutrisi (makan/minum)

3. Eliminasi

4. Gerak Badan

5. Istrirahat tidur

6. Berpakaian

7. Rasa Nyaman

8. Kebersihan Diri

9. Rasa Aman
10. Pola Komunikasi/Hubungan Dengan Orang Lain

11. Ibadah

12. Produktivitas

13. Rekreasi

14. Kebutuhan belajar :

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 TFU:…….............
Leopold II : Kanan : punggung/ bagian kecil/ bokong / kepala
Kiri : 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 :
a. Kebersihan :………………
b. Pengeluaran :…………………. Karakteristik :……………..
c. Hasil VT : ……………………………………………………………….
d. 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 ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas :

III. RENCANA KEPERAWATAN KALA I

No Tgl / jam Diagnosa Rencana Keperawatan
Tujuan Intervensi Rasional
IV. IMPLEMENTASI KALA I

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

V. EVALUASI KALA I
Tgl/Jam No Dx Evaluasi Hasil
KALA II
A. DATA FOKUS KALA II

B. ANALISA DATA KALA II

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas :

C. RENCANA KEPERAWATAN KALA II
No Tgl/jam Diagnosa Rencana Keperawatan
Tujuan Intervensi Rasional

D. IMPLEMENTASI KALA II
Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama
E. EVALUASI KALA II
Tgl/Jam No Dx Evaluasi Hasil
KALA III
A. DATA FOKUS KALA III
B. ANALISA DATA KALA III

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas :

C. RENCANA KEPERAWATAN KALA III

No Tgl/jam Diagnosa Rencana Keperawatan

Tujuan Intervensi Rasional

D. IMPLEMENTASI KALA III

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

E. EVALUASI KALA III

Tgl/Jam No Dx Evaluasi Hasil

KALA IV
A. DATA FOKUS KALA IV

B. ANALISA DATA KALA IV

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas :

C. RENCANA KEPERAWATAN KALA IV

No Tgl/jam Diagnosa Rencana Keperawatan

Tujuan Intervensi Rasional

D. IMPLEMENTASI KALA IV

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

E. EVALUASI KALA IV

Tgl/Jam No Dx Evaluasi Hasil

 Denpasar, …………………….20…..

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

NIP: NIM:

Clinical Teacher/CT 1

NIP:
 ASUHAN KEPERAWATAN PADA By..................
DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........

I PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ............................................
Umur : ............................................
Nama Ayah-Ibu : ............................................
Umur : ............................................
Pendidikan : ............................................
Pekerjaan : ............................................
Status perkawinan : ............................................
Agama : ............................................
Suku : ............................................
Alamat : ............................................
No.CM : ............................................
Tanggal MRS : ............................................
Tanggal pengkajian : ............................................
Sumber informasi : ............................................
B. RIWAYAT KELAHIRAN
No Tahun Jenis BB Keadaan Komplikasi Jenis Ket
Kelahiran Kelamin lahir bayi Persalinan

C. 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.................................Janin ........................
Lamanya ketuban pecah ...................................... Kondisi ketuban....
D. KEADAAN BAYI SAAT LAHIR
Lahir tanggal : ...................jam............ Jenis kelamin.............
Kelahiran : Tunggal/gemeli
Nilai APGAR
Tanda Nilai Jumlah
0 1 2
Denyut Tidak ada < 100 >100
jantung
Usaha napas Tidak ada Lambat Menangis kuat
Tonus otot Lumpuh Ekstremitas Gerakan aktif
fleksi sedikit
Iritabilitas Tidak bereaksi Gerakan sedikit Reaksi
reflex melawan
Warna Biru/pucat Tubuh Kemerahan
kemerahan,
tangan dan kaki
biru

E. PENGKAJIAN FISIK
Umur ..............Hari....................Jam..........

Berat badan.................................gr
Panjang badan.............................cm
Suhu...........................................ºC
Lingkar kepala.............................cm
Lingkar dada...............................cm
Lingkar perut..............................cm

Head to toe
Kepala Wajah
1. Inspeksi : .............................................................
2. Palpasi : .............................................................
Leher
1. Inspeksi : .............................................................
2. Palpasi : .............................................................
Tubuh
1. Warna :……………………………………………
2. Lanugo :……………………………………………
3. Vernix :……………………………………………
Dada
1. Inspeksi : .................................................
2. Palpasi : .................................................
3. Perkusi : .................................................
4. Auskultasi : …………..............................................
Abdomen
1. Inspeksi :.............................................................
2. Auskultasi : ............................................................
3. Perkusi :.............................................................
4. Palpasi : .............................................................
Punggung
1. Keadaan punggung : ...............................................
 2. Fleksibilitas : ...............................................
3. Tulang punggung : ...............................................
4. Kelainan : ...............................................
Genetalia dan anus
1. Laki-laki : ...............................................
2. Perempuan : ...............................................
3. Anus : ...............................................
4. Mekonium : ...............................................
5. Kelainan : ...............................................
Ekstremitas
1. Atas : .............................................................
2. Bawah : .............................................................
3. Kelainan : .............................................................
4. Pergerakan : ...........................................................
F. STATUS NEUROLOGI
Pemeriksaan refleks : .................................................

G. NUTRISI
ASI/PASI/Lain-lain
H. ELIMINASI
BAB pertama, tanggal ........................ Jam..................
BAK pertama, tanggal ........................ Jam..................
I. DATA PENUNJANG
1. Pemeriksaan Laboratorium

2. Pemeriksaan Diagnostik
 J. DIAGNOSA MEDIS

K. PENGOBATAN

II. ANALISA DATA

DATA ETIOLOGI MASALAH
 Diagnosa keperawatan berdasarkan prioritas :

III. RENCANA KEPERAWATAN

No Tgl/jam Diagnosa Rencana Keperawatan
Tujuan Intervensi Rasional

IV. IMPLEMENTASI
 Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

.V EVALUASI
Tgl/Jam No Dx Evaluasi Hasil
 Denpasar, …………………….20…..

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(……………………….) (………………………….)
NIP: NIM:

Clinical Teacher/CT 1

(……..……………… )
NIP
 FORMAT ASUHAN KEPERAWATAN MATERNITAS
“POST NATAL”

ASUHAN KEPERAWATAN PADA Ny..................

DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........
I. PENGKAJIAN
A. IDENTITAS PASIEN PENANGGUNG/ SUAMI
Nama : ............ Nama : ...................
Umur : ............ Umur : ……………
Pendidikan : ............ Pendidikan : ……………
Pekerjaan : ............ Pekerjaan : …................
Status perkawinan : ............ Alamat : ...................
Agama : ............
Suku : ............
Alamat : ............
No. CM : ............
Tangal MRS : ............
Tanggal Pengkajian : ............
Sumber informasi : ............
B. ALASAN DIRAWAT
.1 Alasan MRS
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 .2 Keluhan saat dikaji
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

C. RIWAYAT MASUK RUMAH SAKIT

Keluhan Utama (saat MRS dan sekarang)
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Riwayat persalinan sekarang (kala I-IV)
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 Keadaan bayi sekarang
BB .............................. Lingkar kepala......................Lingkar dada.......................Lingkar
perut...............................dll.......................................
D. RIWAYAT OBSTERTRI DAN GINOKOLOGI
.a Riwayat Menstruasi :
1. Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
2. Banyaknya : .................... Lamanya : .....................................
3. Keluhan : ....................
.b Riwayat Pernikahan :
Menikah : ....................kali Lama : ................. tahun.
.c Riwayat kelahiran, persalinan, nifas yang lalu :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
No Tah Umur Penyu Jen Penolo Penyu Laser Infe Pedara Jenis BB Pj
un kehami lit is ng lit asi ksi han kelamin
lan

.d Riwayat Keluarga Berencana :

1. Akseptor KB : jenis .............. Lama : ..................
2. Masalah : .......................
3. Rencana KB : ......................

.B POLA KEBUTUHAN SEHARI-HARI

1. Bernafas
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2. Nutrisi (makan/minum)
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
3. Eliminasi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4. Gerak Badan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
5. Istrirahat tidur
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Berpakaian ......................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
....................
7. Rasa Nyaman
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
8. Kebersihan Diri
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
9. Rasa Aman
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
10. Pola Komunikasi/Hubungan Dengan Orang Lain
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

11. Ibadah
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
12. Produktivitas
 ..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
13. Rekreasi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
14. Kebutuhan belajar
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

E. PEMERIKSAAN FISIK
Keadaan umum
a. GCS : ......................................
b. Tingkat kesadaran : ......................................
c. Tanda-tanda fital : TD ............. N .............. RR .............. T ...............
d. BB : ................... TB : ............... LILA : ........

Head toe toe :

1. Kepala
Wajah :...........................................................................
Pucat ( )
Cloasma ( )
Sklera :...........................................................................
Konjungtiva : :...........................................................................
Pembesaran Limphe Node :..............................................................
Pembesaran Kelenjar Tiroid :..............................................................
 Telinga : ………………………………………
2. Dada
a. Payudara
b. Areola :…………….. Putting : (menonjol / tidak )
c. Tanda dimpling / retraksi :………………….
d. Pengeluaran ASI : ………………..
e. Jantung : ………. Paru: …………..
3. Abdomen
a. Linea : .................. ................... Striae : ....................
b. Luka SC..............................................................
c. Bising usus : .................
d. TFU : ......................................
e. Kontraksi : ......................................
f. Diastasi rectus abdominis : ......................................
4. Genetalia
a. Kebersihan : ......................................
b. Lokhea : ............................... Krakteristik : ..........................
5. Perineum dan anus
a. Perineum : REEDA .......................
b. Hemoroid : ......................................
6. Ekstremitas
a) Atas
a. Oedema : ......................................
b. Varises : ......................................
c. CRT : ......................................
b) Bawah
a. Oedema : ......................................
b. Varises : ......................................
c. CRT : ......................................
 d. Tanda homan : ......................................
e. Pemeriksaan Reflek : ......................................

F. DATA PENUNJANG
1. Pemeriksaan Laboratorium
 2. Pemeriksaan radiologik

G. DIAGNOSA MEDIS
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

H. PENGOBATAN
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 ................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

II. ANALISA DATA

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas :
......................................................................................................................................................
......................................................................................................................................................
 ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

III. RENCANA KEPERAWATAN

No Tgl/jam Diagnosa Rencana Keperawatan

Tujuan Intervensi Rasional
 IMPLEMENTASI

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

IV. EVALUASI
Tgl/Jam No Evaluasi Hasil
Dx
 Denpasar, …………………….20…..
Mengetahui
Pembimbing Klinik/ CI Mahasiswa
(……………………….) (………………………….)
NIP: NIM

Clinical Teacher/CT 1

(……..……………… )
NIP:

ASUHAN KEPERAWATAN PADA Ny..................

DENGAN.........................................
DI RUANG..........................
 RS………………………..
TANGGAL..........

I. PENGKAJIAN
A. IDENTITAS PASIEN PENANGGUNG/ SUAMI
Nama : ............ Nama : ...................
Umur : ............ Umur : ……………
Pendidikan : ............ Pendidikan : ……………
Pekerjaan : ............ Pekerjaan : …................
Status perkawinan : ............ Alamat : ...................
Agama : ............
Suku : ............
Alamat : ............
No. CM : ............
Tangal MRS : ............
Tanggal Pengkajian : ............
Sumber informasi : ............
B. ALASAN DIRAWAT
.1 Alasan MRS
........................................................................................................................................
.2 Keluhan saat dikaji
..........................................................................................................................................
.........................................................................................................................................
.3 Riwayat gynekologi
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
C. RIWAYAT OBSTERTRI DAN GINOKOLOGI
.a Riwayat Menstruasi :
Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : .................... Lamanya .....................................
Keluhan : ....................

.b Riwayat Pernikahan :
Menikah : ....................kali Lama : ................. tahun.
.c Riwayat kelahiran, persalinan, nifas yang lalu :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
No Tahu Umur Peny Jenis Peno Peny Lase Infeksi Pedar Jenis BB Pj
n keham ulit long ulit rasi ahan kelami
ilan n

.d Riwayat Keluarga Berencana :

Akseptor KB : jenis ............... Lama : ..................
Masalah : .......................
Rencana KB : .......................
D. POLA KEBUTUHAN SEHARI-HARI
1. Bernafas

2. Nutrisi (makan/minum)

3. Eliminasi
 4. Gerak Badan

5. Istrirahat tidur

6. Berpakaian

7. Rasa Nyaman

8. Kebersihan Diri

9. Rasa Aman

10. Pola Komunikasi/Hubungan Dengan Orang Lain

11. Ibadah

12. Produktivitas

13. Rekreasi

14. Kebutuhan belajar

E. PEMERIKSAAN FISIK
Keadaan umum
1. GCS : ......................................
2. Tingkat kesadaran : ......................................
3. Tanda-tanda fital : TD ............. N .............. RR .............. T ...............
4. BB : ................... TB : ............... LILA : ........
Head to toe
1. Kepala Wajah
a. Inspeksi : .............................................................
b. Palpasi : .............................................................

2. Leher
a. Inspeksi : .............................................................
b. Palpasi : .............................................................
3. Dada
a. Inspeksi : .................................................
b. Palpasi : .................................................
c. Perkusi : .................................................
d. Auskultasi : …………..............................................
4. Abdomen
a. Inspeksi :.............................................................
b. Auskultasi : ............................................................
c. Perkusi :.............................................................
d. Palpasi : .............................................................
5. Genetalia
a. Kebersihan : ......................................
b. keputihan : .....................................
6. Perineum dan anus
a. Perineum : .....................................
b. Hemoroid : ......................................
 7. Ekstremitas
a. Atas
Oedema : ......................................
Varises : ......................................
CRT : ......................................
b. Bawah
Oedema : ......................................
Varises : ......................................
CRT : .......................................
Pemeriksaan Reflek : .......................................
F. DATA PENUNJANG
1. Pemeriksaan Laboratorium
 2. Pemeriksaan radiologik

G. DIAGNOSA MEDIS

H. PENGOBATAN

II. ANALISA DATA

DATA ETIOLOGI MASALAH

 Diagnosa keperawatan berdasarkan prioritas :

III. RENCANA KEPERAWATAN

 No Tgl / jam Diagnosa Rencana Keperawatan
Tujuan Intervensi Rasional

IV. IMPLEMENTASI

Tgl/Jam No.Dx Implementasi Evaluasi Proses Paraf/Nama

V. EVALUASI

Tgl/Jam No Dx Evaluasi Hasil

 Denpasar, …………………….20…..

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(……………………….) (………………………….)
NIP: NIM

Clinical Teacher/CT 1

(……..……………… )
NIP