LAPORAN KASUS

Asuhan Keperawatan pada Ny. S dengan Diagnosa G5P4004 37 Minggu 1 Hari Tunggal
Hidup
Di Ruang Poliklinik Kebidanan RSUD Kabupaten Buleleng

Oleh:
NI KOMANG SUARNADI
17089142060

SEKOLAH TINGGI ILMU KESEHATAN BULELENG

PROGRAM PROFESI NERS
2017
 Lembar Pengesahan

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Telah disahkan dan diterima oleh Clinical Instruktur (CI) dan Clinical Teacher (CT)
Stase Keperawatan Maternitas sebagai syarat memperoleh nilai dari Departement
Keperawatan Maternitas Program Profesi Ners STIKes Buleleng.

.................. September 2017

Clinical Instructure (CI) Clinical Teacher (CT)
Ruang Poli Kebidanan Stase Keperawatan Maternitas
RSUD Kabupaten Buleleng STIKes BULELENG,

Made Muncarining,A.Md.Keb ...............................................................

………… NIK.
NIP. 196901111989032008
 FORMAT ASUHAN KEPERAWATAN MATERNITAS
”ANTENATAL”

A. PENGKAJIAN
IDENTITAS PASIEN PENANGGUNG/ SUAMI
Nama : ………………………… Nama : ...............
Umur : ………...…...………….. Umur :...............
Pendidikan : ........................................ Pendidikan : ...............
Pekerjaan : ........................................ Pekerjaan : ...............
Status perkawinan : ........................................ Alamat : ...............
Agama : .......................................
Suku : .......................................
Alamat : .......................................
No. CM : ........................................
Tanggal pengkajian : .......................................
Sumber informasi : .......................................

RIWAYAT PENYAKIT
Keluhan Utama
..............................................................................................................................................
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Riwayat Penyakit Sekarang

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

Riwayat Penyakit Dahulu (termasuk genogram kalau diperlukan)

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RIWAYAT OBSTETRI DAN GINEKOLOGI

1. Riwayat Menstruasi :
● Menarche : umur .......... Siklus : teratur ( ) tidak ( )
● Banyaknya : ................... Lamanya : .............................
● Keluhan : ...................
● HPHT : ...................

2. Riwayat pernikahan :
● Menikah : .......... kali Lama : .......... tahun
 3. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

Jenis
Umur Penyul Lasera Perdar
No Tahun Penyulit Jenis Penolong Infeksi kelami BB PB
kehamilan it si ahan
n

4. Riwayat Kehamilan Saat ini:

Status Obstetri :
● G....P....A....H.... UK : .............minggu
● HPHT: ................
● Tapsiran Partus : .............
● ANC kehamilan sekarang : ...........................................

5. Riwayat Keluarga Berencana :

● Akseptor KB : jenis ............. Lama : .............
● Masalah : ......................

POLA FUNGSIONAL KESEHATAN

1. Pemeliharaan dan persepsi terhadap kesehatan
...........................................................................................................................................
....................................................................................................................................

2. Nutrisi/ metabolik
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...........................................................................................................................................
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3. Pola eliminasi
...........................................................................................................................................
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4. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total.
 Oksigenasi: .......................................................................................................................
...........................................................................................................................................
...................
5. Pola tidur dan istirahat
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………………………………………………………………………………………….

6. Pola perseptual
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7. Pola persepsi diri

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8. Pola seksual dan reproduksi

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9. Pola peran-hubungan
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10. Pola manajemen koping stress

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11. Sistem nilai dan keyakinan

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PEMERIKSAAN FISIK
1. Keadaan umum:
 GCS : ................................................
 Tingkat kesadaran : ................................................
 Tanda-tanda vital : TD: ............. N: .......... RR:....... Suhu: ........
 BB: ............... TB : .......... LILA :........
2. Head to toe:
 Kepala Wajah :
 Inspeksi: ................................................................................................................
...............................................................................................................................
........
  Palpasi: .................................................................................................................
...............................................................................................................................
........

 Leher :
 Inspeksi: ................................................................................................................
...............................................................................................................................
...............

 Palpasi: .................................................................................................................
...............................................................................................................................
........
 Dada :
 Inspeksi : Payudara
Areola............................... Puting : (menonjol/tidak)
Tanda dimpling/ retraksi : ...........................
 Palpasi : Pengeluaran ASI...........................
 Perkusi : ................................................................................................
 Auskultasi : Jantung......................... Paru.............................

 Abdomen :
 Inspeksi : Linea : ................ Striae : .................
Pembesaran sesuai UK : ..................
Gerakan janin: ...................... Kontraksi : ...............
Luka bekas operasi : ..........................
 Palpasi :
Ballotement : ....................
Leopold I :.......................................... TFU : ...............
Leopold II : Kanan: .........................................................
Kiri : .............................................................
Leopold III : .....................................................................
Leopold IV :...................................................................
Penurunan kepala : .................
Kontraksi : ..................................
 Auskultasi : DJJ : .................. Bising Usus : .......................

 Genetalia dan perineum:

 Kebersihan : ...............................................
 Keputihan : ............................................... Karakteristik : ...................
 Hemoroid : ...............................................

 Ektremitas:
  Atas :
Oedema : ........................
Varises : ........................
CRT : ........................
 Bawah :
Oedema : .......................
Varises : .......................
CRT : .......................
Refleks : .......................

DATA PENUNJANG
1. Pemeriksaan Penunjang

Darah Lengkap / Urologi

Tanggal :........................................................
Hasil :

Rontgen / Radiologi / USG

Tanggal :........................................................
Hasil :
2. Terapi

No Nama obat Dosis

B. ANALISA DATA

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas:
1. ...........................................................................................................................................
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2. ...........................................................................................................................................
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3. ...........................................................................................................................................
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C. RENCANA KEPERAWATAN

NO DIAGNOSA RENCANA KEPERAWATAN

TUJUAN INTERVENSI RASIONAL
D. IMPLEMENTASI

TGL/JAM NO IMPLEMENTASI EVALUASI PARAF/

DX NAMA
E. EVALUASI/ CATATAN PERKEMBANGAN

TGL/ EVALUASI
JAM DIAGNOSA