ASUHAN KEPERAWATAN

PADA Px. ………. DENGAN PENYAKIT…………………………

DI RUANG……………………………… RS. ……………………………………………

NAMA : ……………………………………………………………………

NIM : ……………………………………………………………………

PROGRAM STUDI PROFESI NERS

STIKes BINA SEHAT PPNI KAB. MOJOKERTO

TA. 2018-2019
 LEMBAR PENGESAHAN

Laporan asuhan keperawatan ini diajukan oleh:

Nama : ...............................................................
NIM : ...............................................................
Program Studi : ...............................................................
Judul Asuhan Keperawatan :
................................................................................................................................................................
................................................................................................................................

Telah diperiksa dan disetujui sebagai tugas dalam praktik klinik keperawatan dasar.

................................ , ............................
Preseptor (preseptor)ruangan, Preseptor (preseptor)akademik,

(.................................................) (.....................................................)
Mengetahui,
Kepala Ruangan

(..................................................)
 LAPORAN PENDAHULUAN

I. Konsep Penyakit …………………………..

1.1 Definisi/deskripsi kebutuhan…………
1.2 Batasan karakteristik (data mayor minor)
1.2 Fisiologi sistem/ Fungsi normal sistem………………
1.3 Faktor-faktor yang mempengaruhi perubahan fungsi sistem…………
1.4 Macam-macam gangguan yang mungkin terjadi pada sistem…………

II. Rencana Asuhan Klien Dengan Penyakit ……………….

2.1 Pengkajian
2.1.1 Riwayat keperawatan
2.1.2 Pemeriksaan fisik: data fokus
2.1.3 Pemeriksaan penunjang

2.2 Diagnosa Keperawatan yang mungkin muncul

(Minimal 2 diagnosa keperawatan yang sering muncul, penjelasan berdasarkan
buku saku diagnosa keperawatan)
Diagnosa 1: …………………………….
2.2.1 Definisi
2.2.2 Batasan karakteristik
2.2.3 Faktor yang berhubungan
Diagnosa 2: ……………………………
2.2.4 Definisi
2.2.5 Batasan karakteristik
2.2.6 Faktor yang berhubungan

2.3 Perencanaan
(Berdasarkan dua diagnosa pada 2.2)
Diagnosa1:……………………………………
2.3.1 Tujuan dan Kriteria hasil (outcomes criteria): berdasarkan NOC (lihat daftar
rujukan)
2.3.2 Intervensi keperawatan dan rasional: berdasarkan NIC (lihat daftar
rujukan)
Diagnosa 2: ……………………………………
2.3.3 Tujuan dan Kriteria hasil (outcomes criteria): berdasarkan NOC (lihat daftar
rujukan)
2.3.4 Intervensi keperawatan dan rasional: berdasarkan NIC (lihat daftar rujukan)

III. Daftar Pustaka

1. Bobak, I.M. & Jensen, M.D. (2005). Maternity and gynecologic care: the nurse and the family. 5th. ed.
Saint Louis: CV Mosby Co.
2. Pilliteri, A. (2003). Maternal & child health nursing: Care of the childbearing and childrearing family. 4th
ed. Philadelphia: Lippincott.
3. May, K. A. & Mahlmeister, L. R. (1994). Maternal and neonatal nursing: Family-centered care. 3rd ed.
Philadelphia: JB Lippincott.
4. Reeder, S.J., Martin, L.L., & Griffin, K.D. (1999). Maternity nursing: Family, newborn & women’s health .
8th ed. Philadelphia: Lippincott.
5. Rachmawati, I. N., Afiyanti, Y., Rahmawati, C. (2007). Buku Panduan Praktik Profesi Keperawatan
Maternitas. Jakarta: Lembaga Penerbit Fakultas Ekonomi UI
6. Rachmawati, I. N., Budiati, T., Rahmawati, C. (2008). Panduan Praktikum Prosedur Pemeriksaan Fisik
Antenatal. Depok: Tidak dipublikasikan
7. Noer Saudah, Indah Lestari, Catur Prasastia LD (2018) Asuhan Keperawatan pada kehamilan Patologis.
CV. Karya Bina Sehat. Mojokerto
8. Noer Saudah (2017) Untervensi Keperawatan Experiential Learning Care (ELC) pada ibu dan Bayi
Preterm. Indomedika Pustaka. Jogjakarta
 FORMAT ASUHAN KEPERAWATAN MATERNITAS (OBSTETRI)
PROGRAM STUDI PROFESI NERS
STIKes BINA SEHAT PPNI KAB. MOJOKERTO

PENGKAJIAN
Tanggal MRS : ........................................................
Ruang : ........................................................
No. Register : ........................................................
Diagnosa Medis : ........................................................
Tanggal Pengkajian : ...........................................................

A. IDENTITAS PASIEN:
- Nama : ........................................................
- Umur : ........................................................
- Suku/Bangsa: ....................................................
- Bahasa : ........................................................
- Pekerjaan : ........................................................
- Status : ........................................................
- Alamat : ........................................................
- Nama Suami: .....................................................
- Pekerjaan : ........................................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA
……………………………………………………………………………………….

2. RIWAYAT KESEHATAN SEKARANG

……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
3. RIWAYAT PENYAKIT DAHULU
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….

4. RIWAYAT PENYAKIT KELUARGA

……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….

5. Riwayat Obstetri
Riwayat Kehamilan Sekarang : G.................P................A...............
HPHT : ............................................................................

Gerakan janin : ............................................................................

Keluhan tiap trimester :..........................................................................

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

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

Riwayat nifas : ............................................................................

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

Imunisasi TT : ............................................................................

Obat yang dikonsumsi : Obat (................................................................)

Jamu (................................................................)

6. Riwayat Haid
Menarche : …………………………………………

Siklus : …………………………………………

Lamanya : …………………………………………

Banyaknya : …………………………………………

Desmenorhoe : …………………………………………

7. Riwayat Kehamilan, nifas dan persalinan yang lalu

Hamil Ke Tgl Usia Jenis Penolong Penyulit Anak Nifas
Kehamilan kehamilan &
Partus partus Persalianan JK BB PB ASI Penyulit

8. Riwayat Ginekologi
Infertilitas : ....................................................................................................

Masa : ....................................................................................................

Penyakit : ....................................................................................................

Operasi : ....................................................................................................

9. Riwayat KB
Kontrasepsi yang dipakai : ............................................................................

Keluhan : ……………………………………………........

Kontrasepsi yang lalu : …………………………………………............

Lamanya pemakaian : ……………………………………………........

Alasan berhenti : ............................................................................

10. Pola Gordon ( 11 atau sesuai dengan kondisi klien )

PEMERIKSAAN FISIK
1. Kesadaran
(__) Komposmentis

(__) Somnolent

(__) Sopor

(__) Sopor komatus

(__) Komatus

2. Tanda-tanda Vital
Nadi ……………X/mnt

Suhu …………...X/mnt

Tensi …………..mmHg

Respirasi ……….X/mnt

3. Kepala
Rambut : …………………………………………………………………

Mata : Konjungtiva : …………………………………………………

Sclera : …………………………………………………

Pengelihatan : …………………………………………………

Telinga : …………………………………………………………………

Hidung : …………………………………………………………………

…………………………………………………………………

Mulut : …………………………………………………………………

Leher : …………………………………………………………………

…………………………………………………………………

…………………………………………………………………

4. Thorax
Dada : Bentuk simetri : Ya (__) Tidak (__)
 Mamae : Bentuk simetris : Ya (__) Tidak (__)

Puting Susu : ………………………………………....

Benjolan : …………………………………………

Ekskresi : …………………………………………

Paru-paru : …………………………………………………………………

Jantung : …………………………………………………………………

5. Abdomen
Inspeksi: Bentuk : …………………………………………………

Striae : ……………………………………....................

Bekas luka Operasi : ………………………………..................

Palpasi : Tinggi Fundus Uteri : ………… …Cm

Lingkar Perut : .................... Cm

Posisi Janin : Leopold I : ……………………………………...

Leopold II : ……………………………………..

Leopold III :…………………………………….

Leopold IV : ……………………………………

Kontraksi Uterus : frekuensi :……………………………….

Interval : ……………………………...

Intensitas : ……………………………

Auskultasi DJJ : .............................................................................................

6. Genetalia Luar
Bentuk : …………………………………………………………………

Varices : …………………………………………………………………

Oedema : …………………………………………………………………

Massa / Kista : ....................................................................................................

Pengeluaran pervigam : .......................................................................................

 7. Ekstremitas (tangan & kaki)
Bentuk : Kaki : ................................. Tangan : .......................................

Kuku : Kaki : ................................ Tangan : .......................................

Refleks Patela : ................................

Oedema : ................................

8. Kulit
Warna : ....................................

Turgor : ....................................

DATA PENUNJANG (LABORATORIUM)

a. Pemeriksaan urine
Protein : .........................................

Reduksi : .........................................

b. Pemeriksaan darah
Hb : .............................

Golongan darah : .............................

c. Pemeriksaan lain-lain bila diperlukan

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

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

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

TERAPI
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….

ANALISA DATA
Nama Pasien: No. Reg:
NO
DATA ETIOLOGI MASALAH TTD
Dx

DAFTAR DIAGNOSIS
Nama Pasien: No. Reg:
NO DIAGNOSIS KEPERAWATAN TTD

3
 RENCANA KEPERAWATAN

Nama Pasien: No. Reg:

NO TUJUAN &
INTERVENSI RASIONAL
Dx KRITERIA HASIL
 EVALUASI KEPERAWATAN

Nama Pasien: No. Reg:

NO EVALUASI TTD
Dx S-O-A-P
1

3
 FORMAT RESUME KEPERAWATAN MATERNITAS

Nama Preseptee :
NIM :
Tempat Praktek :
Tanggal :

A. Identitas Klien
Nama : ………………………….. L/P
Tempat & Tgl lahir : ....................................... Gol Darah : O / A / B / AB
Pendidikan Terakhir : ....................................................................................
Agama : ....................................................................................
Status perkawinan : ....................................................................................
Pekerjaan : ....................................................................................
TB/BB : ……….. cm/ …… kg
Alamat : ....................................................................................
.............................................................................................................................
Tanggal Pengkajian :......................................................................................

B. RESUME KEPERAWATAN
NO PROBLEM IMPLEMENTASI EVALUASI
1 DS :
DO :
DX :

2 DS :
DO :
DX :

3 DS :
DO :
DX :

...............................,.................................2018
Preseptee (preseptee)Ners,

(............................................)
 FORMAT ASUHAN KEPERAWATAN MATERNITAS (GINEKOLOGI)
PROGRAM STUDI PROFESI NERS
STIKes BINA SEHAT PPNI KAB. MOJOKERTO

I. PENGKAJIAN
Tanggal MRS : ........................................................
Ruang : ........................................................
No. Register : ........................................................
Diagnosa Medis : ........................................................
Tanggal Pengkajian : ...........................................................

A. IDENTITAS PASIEN:
- Nama : ........................................................
- Umur : ........................................................
- Suku/Bangsa: ....................................................
- Bahasa : ........................................................
- Pekerjaan : ........................................................
- Status : ........................................................
- Alamat : ........................................................
- Nama Suami: .....................................................
- Pekerjaan : ........................................................

B. STATUS KESEHATAN
11. KELUHAN UTAMA
……………………………………………………………………………………….

12. RIWAYAT PENYAKIT SEKARANG

……………………………………………………………………………………….
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13. RIWAYAT PENYAKIT DAHULU
……………………………………………………………………………………….
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14. RIWAYAT PENYAKIT KELUARGA
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
 KEADAAN UMUM :
Tanda-tanda vital: Nadi : _____ SUHU : _____ RR : _____ TD: ________

II. PENGKAJIAN SISTEM

1. B1 (BREATING)
……………………………………………………………………………………….
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2. B2 (BLOOD)
……………………………………………………………………………………….
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3. B3 (BRAIN)
……………………………………………………………………………………….
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 4. B4 (BLADDER)
……………………………………………………………………………………….
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5. B5 (BOWEL)
……………………………………………………………………………………….
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6. B6 (BONE)
……………………………………………………………………………………….
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III. PEMERIKSAAN PENUNJANG

 ……………………………………………………………………………………….
……………………………………………………………………………………….
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IV. TERAPI
……………………………………………………………………………………….
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……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….
……………………………………………………………………………………….

ANALISA DATA
Nama Pasien: No. Reg:
NO
DATA ETIOLOGI MASALAH TTD
Dx

3
 DAFTAR DIAGNOSIS

Nama Pasien: No. Reg:

NO DIAGNOSIS KEPERAWATAN TTD

3
 RENCANA KEPERAWATAN

Nama Pasien: No. Reg:

NO TUJUAN &
INTERVENSI RASIONAL
Dx KRITERIA HASIL
 EVALUASI KEPERAWATAN

Nama Pasien: No. Reg:

NO EVALUASI TTD
Dx S-O-A-P
1