DI RUMAH SAKIT…………….........................
Oleh :
Oleh:
NamaMahasiswa NIM Mahasiswa
Disetujui pada:
Hari :
Tanggal
Kepala Ruang
Nama, Gelar
NIP
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PENGKAJIAN
FORMAT PENGKAJIAN
I. Identitas
Nama klien :............................ Nama suami :.........................
Umur :...................... ...... Umur :.........................
Suku/bangsa :............................ Suku/bangsa :.........................
Agama :............................ Agama :.........................
Pendidikan :............................ Pendidikan :.........................
Pekerjaan :............................ Pekerjaan :.........................
Alamat :............................ Alamat :.........................
Status perkawinan :............................
V. Riwayat Obsterti
1. Riwayat Menstruasi
Menarche : umur...........th HPHT :......................................
Banyaknya :....................... Sikulus : teratur ( ) tidak ( )
Warna :...................... Lainnya :.........................
Bentuk haid : encer/bergumpal/flek/lainnya...................................
Bau haid : anyir/busuk/lainnya................................................
Keluhan : fluor albus/dismenorhoe/spoting/menorraghia/metrorhagia/PMS
Lainnya.......................................................................
5. Riwayat Nifas
Tanggal...............................jam..........................................
Invulutio :
- TFU :.................................................................
- Kontraksi :......................................................
Lochea :
- Warna :.................................................................
- Jumlah :.................................................................
- Jenis :.................................................................
Laktasi :
- Kolostrum :............................................................
- ASI :.....................................................................
Keluhan lain :
...................................................................................................................................
7. Riwayat KB
Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan :...................................................
Sejak kapan menggunakan kontrasepsi :................................................................
Masalah yang terjadi :..........................................................................................
BAB
1) Frekuensi :..................x/hari
2) Warna :..........................
3) Bau :..........................
4) Konsistensi :..........................
5) Keluhan :.......................................................................................................
c. Pola Personal Hygiene
1) Mandi
Frekuensi :......................x/hari
Sabun : ( ) ya ( ) tidak
2) Oral hygiene
Frekuensi :.......................x/hari
Waktu : ( ) pagi ( ) sore ( ) setelah makan
3) Cuci rambut
Frekuensi :.......................x/hari
shampo : ( ) ya ( ) tidak
4) Keluhan
:...........................................................................................................................
d. Pola istirahat tidur
1. Lama tidur :.......................................................................................................
2. Kebiasaan sebelum tidur :.............................................................................
3. Keluhan :.......................................................................................................
e. Pola aktivitas dan latihan
1. Kegiatan dalam pekerjaan :.............................................................................
2. Waktu bekerja : ( ) pagi ( ) sore ( ) malam
3. Olahraga : ( ) ya ( ) tidak
Jenisnya :...........................................
Frekuensi :...........................................
4. Kegiatan waktu luang :.............................................................................
5. Keluhan dalam aktivitas :.............................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
1. Merokok :..............................................
2. Minuman keras :...................................
3. Ketergantungan obat :.............................
X. Pemeriksaan Fisik
Keadaan umum :.................... Kesadaran :......................
Berat badan :............Kg Tinggi badan :.........................
a. Tanda-tanda Vital :
- Suhu :.......................
- TD :.......................
- RR :.......................
- N :........................
b. Pemeriksaan kepala dan leher :
- Kepala-rambut :..........................................................................................
- Wajah :..........................................................................................
- Mata :..........................................................................................
- Telinga :..........................................................................................
- Mulut/faring :..........................................................................................
- Leher :..........................................................................................
c. Pemeriksaan integumen :
- Warna :..........................................................................................
- Turgor :..........................................................................................
- Tekstur/kekenyalan :.............................................................................
- Kelembaban :..........................................................................................
- Kelainan pada kulit :.............................................................................
d. Dada / thorax :
- Paru
:.....................................................................................................................
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- Jantung :
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e. Payudara :
- Inspeksi :......................................................................................................
- Palpasi :......................................................................................................
- Produksi ASI (kolostrum) :..........................................................................
- Keluhan :......................................................................................................
f. Pemeriksaan abdomen :
- Inspeksi :..........................................................................................
- Palpasi :..........................................................................................
- Auskultasi :..........................................................................................
- Keluhan :..........................................................................................
g. Pemeriksaan genetalia :
- Inspeksi :..........................................................................................
- Palpasi :..........................................................................................
- Lochea/perdarahan :.....................................................................................
- Keadaan rektum :.........................................................................................
- Keluhan :..........................................................................................
h. Pemeriksaan muskuloskeletal :
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1. Laboratorium :...........................................................................................................
2. NST,CST :.................................................................................................................
3. USG :.........................................................................................................................
4. Rontgen :...................................................................................................................
5. Terapi yang di dapat :................................................................................................
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Kota...................
Pemeriksa
(...............................)
ANALISA DATA
MASALAH
NO DATA ETIOLOGI
KEPERAWATAN
DAFTAR DIAGNOSA KEPERAWATAN
.
RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan:
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Tujuan:
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Kriteria Hasil :
NOC
No. Indikator 1 2 3 4 5
Keterangan Penilaian :
1 :
2 :
3 :
4 :
5 :
NIC :
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IMPLEMENTASI
S:
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O:
NOC:
Score
Indikator
Awl Tgt Akr
O:
A:
P:
RESUME KEPERAWATAN
NAMA KLIEN : ......................................... TANGGAL : .........................................
DX. MEDIS : ......................................... RUANG : .........................................
S O A P I E
SATUAN ACARA PENYULUHAN
Topik Penyuluhan :
Sasaran :
Tempat :
Hari/Tanggal :
Waktu :
III. Materi
1. ………………….
2. ………………….
IV. Metode
1. Ceramah
2. Diskusi
3. Tanya Jawab
V. Media
1. Leaflet
2. Lembar balik
VI. Pelaksanaan
No Tahap Kegiatan Penyuluh Kegiatan Peserta
Kegiatan
1. Pembukaan - -
(5 menit)
2. Penyajian - -
(20 menit)
3. Penutup - -
(5 menit)
VIII. Koordinasi
Moderator :
Penyaji :
Notulen :
IX. Evaluasi
Struktur :
Proses :
Hasil :
X. Lampiran Materi Penyuluhan