ASUHAN KEPERAWATAN PADA PASIEN …………..

UMUR..........DI ……………………....

I. PENGKAJIAN
Tanggal : ................................................................
Jam : ................................................................
Tempat : ................................................................
Nama Mahasiswa : ................................................................
Tanda Tangan : ..............................................................

DATA SUBYEKTIF
A. Identitas Klien
Nama ibu :............................... Nama suami :....................................
Umur :............................... Umur :....................................
Suku bangsa :............................... Suku Bangsa :....................................
Agama :............................... Agama :....................................
Pendidikan :............................... Pendidikan :....................................
Pekerjaan :............................... Pekerjaan :....................................
Alamat :............................... Alamat :....................................

B. Keluhan Utama:
.....................................................................................................................................
.....................................................................................................................................
Riwayat Perjalanan Penyakit:
.....................................................................................................................................
.....................................................................................................................................
...................................................................................................................................
C. Data Kebidanan
1. Haid
Menarche umur : ................................tahun
HPHT : ...............................
Haid : Teratur Tidak teratur
Lama Haid : ............................... hari
Siklus : ............................... hari
Dismenorhea : Ya/Tidak
Warna : Merah tua Merah segar

Merah kehitaman Coklat

Bentuk Perdarahan/Haid : Encer Bergumpal Flek
Bau Haid : Anyir Busuk
Flour albus : Banyak Sedikit

Kapan : Sebelum haid Sesudah haid

Lama : ..............................hari
Warna : .............................................................................
Banyak : .............................................................................
 2. Riwayat Perkawinan
Status Perkawinan: Kawin Ya Tidak
Jika Kawin : Berapa kali: .........lamanya..........................Usia ...............tahun

3. Riwayat kehamilan, persalinan dan nifas yang lalu

Persalinan
Hamil Ket
ke Tgl Umur Jenis BB
Penolong Penyulit JK
lahir kehamilan Persln lahir

4. Riwayat KB
Pernah mendengar tentang KB : Pernah Tidak pernah
Pernah menjadi akseptor KB : Pernah Tidak pernah
Alat kontrasepsi yang pernah dipakai : Suntik Pil

Implan IUD
Tidak KB Lain-lain

Alasan berhenti menjadi akseptor : ........................................................

D. Riwayat kesehatan :
1. Riwayat kesehatan keluarga
Keturunnan kembar : Ada Tidak
Penyakit menular/keturunan : hepatitis Jantung
Hipertensi TB
Diabetes mellitus Lain-lain
Lain-lain, jelaskan : ........................................................................
2. Perilaku kesehatan yang lalu
Penyakit menular/keturunan : hepatitis Jantung
Hipertensi TB
Diabetes mellitus Lain-lain
Lain-lain, jelaskan : ........................................................................

DATA OBYEKTIF
A. Pemeriksaan Fisik
1. Keadaan umum : Lemah Baik Cukup
2. Kesadaran : ........................................................................
3. Tanda-tanda vital :
Tekanan darah : ......................................mmHg
Nadi : ......................................x/menit
Temperatur : ......................................⸰C
Pernafasan : ......................................x/menit
Berat badan : ......................................kg
Tinggi badan : ......................................cm
Lingkaran lengan atas : ......................................cm
4. Pemeriksaan fisik umum
a. Kepala
Wajah : Pucat Sianosis
Rambut : Kebersihan : ......................................
Rontok : Ya Tidak
 Cloasma gravidarum : Ada Tidak ada
Konjungtiva : Pucat Merah muda
Hiperemi
Sklera : Putih Ikterus
Pendarahan
Mulut dan gigi : Karies Stomatis
: Trismus Pendarahan gusi
Lidah : Bersih Kotor
Telinga : Serumen Pendarahan
Lain-lain jelaskan : ...............................................................
b. Leher
Pembesaran kelenjar tyroid : ...............................................................
Pembesaran kelejar limfe : ...............................................................
Pembesaran vena jugularis : ...............................................................
Lain-lain,jelaskan : ...............................................................
c. Dada
Tarikan : Ada Tidak
Bentuk : Simetris Asimetris
Mammae : Radang Ada benjolan
Tidak ada benjolan
Puting susu : Menonjol Datar Masuk
: Bersih Kotor
Areola mammae : Hipopigmentasi aerola/papilla
Colostrum : Keluar Belum
Pembesaran mammae : Simetris Asimetris
d. Abdomen
Pembesaran perut : Simetris Asimetris
Linea : Alba Nigra
Striae : Albicans Livida
Bekas luka operasi : Ya Tidak
e. Genetalia Eksterna
Labia mayora/minora : Simetris Asimetris
Pembengkakkan kelenjar bartholini : Ada Tidak
Pengeluaran vagina
 Jenis sekret : ...........................................................
 Bau : ...........................................................
 Jumlah : ...........................................................
f. Ekstremitas : Edema Varises Simetris
Asimetris
Kelainan jelaskan : ...........................................................

5. Pemeriksaan Ginekologi :
a. Pemeriksaan luar :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
b. Inspekulo :
Portio : ................................................................................
Fluksus : ................................................................................
Fluor : ................................................................................
Erosi : ................................................................................
 Laserasi : ................................................................................
Polip : ................................................................................
Cavum Douglas : ................................................................................
c. Pemeriksaan bimanual :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
B. Pemeriksaan Laboratorium
a. Darah rutin
Hb : ........................
Leukosit : ........................
Eritrosit : ........................
Trombosit : ........................
Hematokrit : ........................
Golongan darah : A B AB O
b. Kimia darah
GDS : ........................
SGOT : ........................
SGPT : ........................
Ur : ........................
Kr : ........................
Albumin : ........................
Globulin : ........................
c. Urine
Protein : ........................
Glukosa : ........................
DIAGNOSIS ASSESMENT
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

ANALISA DATA
Nama Klien:
Umur:
KEMUNGKINAN
DATA MASALAH
PENYEBAB
DIAGNOSA KEPERAWATAN
Nama Klien:
Umur:
TANGGAL TANGGAL TANDA
NO DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
 CATATAN KEPERAWATAN
Nama Klien:
Umur:

TGL/ DIAGNOSA TUJUAN DAN TANDA

JAM KRITERIA HASIL INTERVENSI
KEPERAWATAN TANGAN
 CATATAN KEPERAWATAN
Nama Klien:
Umur:

TGL/ DIAGNOSA TANDA

JAM IMPLEMENTASI
KEPERAWATAN TANGAN
CATATAN PERKEMBANGAN
Nama Klien:
Umur:
NO TANGGAL/ DIAGNOSA TANDA
PERKEMBANGAN (SOAP)
JAM KEPERAWATAN TANGAN