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FORMAT ASUHAN KEPERAWATAN ANTENATAL

ASUHAN KEPERAWATAN PADA Ny…………………


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

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :
Umur :
Pendidikan :
Pekerjaan :
Status Perkawinan :
Agama :
Suku :
Alamat :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
Penanggung Jawab
Nama :
Umur :
Pendidikan :
Jenis kelamin :
Pekerjaan :
Alamat :
Status perkawinan :
Agama :

B. ALASAN KUNJUNGAN
a. Keluhan Utama/Alasan ke Poliklinik
b. Keluhan saat dikaji (jika ada)

C. RIWAYAT OBSTETRI DAN GINEKOLOGI


a. Riwayat Menstruarsi :
 Menarche : umur …........ Siklus : teratur ( ) tidak ( )
 Banyaknya :….................. Lama :……….......................
 Keluhan :……......................................................................
.............................................................................
.............................................................................
.............................................................................
 HPHT :………..................................................................

b. Riwayat pernikahan
 Menikah : ..........….kali Lama : …...........tahun

c. Riwayat kehamilan, persalinan, nifas yang lalu :


Anak Kehamilan Persalinan Komplikasi nifas Anak
Ke
N Th Umur Penyu jen penolo Penyu laser infe Perdara Jenis B P
o n kehami lit is ng lit asi ksi han Kela B j
lan min
d. Riwayat kehamilan saat ini
Status Obstetrikus :
 G.....…P.....…A......…H…...... UK : …..…..minggu
 TP : …....................................................................................
 ANC kehamilan sekarang :………..........................................

e. Riwayat keluarga berencana


 Akseptor KB : ….............. Jenis:......…… Lama:…...…....
 Masalah : ……............................................................
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D. RIWAYAT PENYAKIT
1. Klien :………….................................................................
................................................................................
................................................................................
2. Keluarga : …………................................................................
................................................................................
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................................................................................

E. POLA FUNGSIONAL KESEHATAN


1. Pola Manajemen Kesehatan-Persepsi Kesehatan
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2. Pola Metabolik-Nutrisi
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3. Pola Eleminasi
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4. Pola Aktivitas-Latihan
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5. Pola Istirahat-Tidur
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6. Pola Persepsi-Kognitif
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7. Pola Konsep Diri-Persepsi Diri


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8. Pola Hubungan-Peran
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9. Pola Reproduktif-Seksualitas
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10. Pola Toleransi Terhadap Stres-Koping


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11. Pola Keyakinan-Nilai


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F. PEMERIKSAAN FISIK
Keadaan umum :
 GCS :E…………V………..M...............
 Tingkat kesadaran : …………………............................................
 Tanda – tanda vital : TD….. ...........N….........RR….........T…........
 BB : ………….TB:………… LILA :………............

Head toe toe :


 Kepala
wajah : ................................................................. .........
Pucat ( )
Cloasma ( )

sklera : ..................................................................... .....


konjungtiva :...................................................................
pembesaran limphe node : ............................................
pembesaran kelenjar tiroid : ............................................

telinga : ………………………………………

 Dada
Payudara:
Areola :…………….. Putting : (menonjol / tidak )
Tanda dimpling / retraksi :…………………..................
Pengeluaran ASI : ……………….....................
Jantung : ………................................
..........................................
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...........................................
Paru : …………............................
..........................................
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...........................................

 Abdomen
Linea : ………................................
..........................................
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Striae : ………................................
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Pembesaran sesuai UK : ………….............................
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Gerakan Janin : ………….............................
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Kontraksi : ……....................................
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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 : …………………..

 Genetalia dan perineum :


Kebersihan :………………
Keputihan :………………….
Karakteristik :……………..
Hemoroid :…………………
 Ekstremitas
Atas :
Oedema :…………………
Varises :…………………
CRT :…………………
Bawah :
Oedema :…………………
Varises :…………………
CRT :…………………
Refleks :………………....

G. DATA PENUNJANG
 Pemeriksaan Laboratorium :………………………..
 Pemeriksaan USG :………………………..

H. DIAGNOSA MEDIS

I. PENGOBATAN
II. ANALISA DATA
DATA FOKUS ANALISIS MASALAH

Diagnosa keperawatan berdasarkan prioritas :


1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
4. ...............................................................................................................
5. ...............................................................................................................

III. RENCANA KEPERAWATAN

N Tgl / Nomor Rencana Keperawatan


o jam Diagnosa Tujuan Intervensi Rasional

IV. IMPLEMENTASI
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
V. EVALUASI
Tgl/Jam No Dx Evaluasi Hasil Paraf
Denpasar, …………………….20…..
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(…………......................…………….) (……………………...............…….)
NIP: NIM:

Clinical Teacher/CT

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

ASUHAN KEPERAWATAN PADA Ny…………………


DENGAN……………………………………...................
DI RUANG …………………………………...................
RS……………...........................................................
TANGGAL ………………….......................................
I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :
Umur :
Pendidikan :
Pekerjaan :
Status Perkawinan :
Agama :
Suku :
Alamat :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
Penanggung Jawab
Nama :
Umur :
Pendidikan :
Jenis kelamin :
Pekerjaan :
Alamat :
Status perkawinan :
Agama :
B. DATA KESEHATAN
a. Keluhan Utama :

b. Keluhan saat dikaji :


c. Riwayat keluhan (kaji data mulai dari timbulnya keluhan sampai dengan
dilakukan asuhan keperawatan)

RIWAYAT OBSTETRI DAN GINEKOLOGI


1.Riwayat Menstruarsi :
 Menarche : umur ….. Siklus : teratur ( ) tidak ( )
 Banyaknya :…. Lama :………
 Keluhan :………
 HPHT :………..

2.Riwayat pernikahan
 Menikah : ….kali Lama : ….tahun

f. Riwayat kehamilan, persalinan, nifas yang lalu :


Anak Kehamilan Persalinan Komplikasi nifas Anak
Ke
N Th Umur Peny jen penolo Peny Laser infe Perdara Jenis B P
o n kehami ulit is ng ulit asi ksi han Kela B j
lan min
g. Riwayat kehamilan saat ini
Status Obstetrikus :
 G…P…A…H… UK : ……..minggu
 TP : ….
 ANC kehamilan sekarang :………...........................................
Trimester I :…………………………………………………………
Trimester II : …………………………………………………….....
Trimester III : ……………………………………………………....

h. Riwayat keluarga berencana


 Akseptor KB : …...
 Jenis : ……
 Lama : ………
 Masalah : ……

D. RIWAYAT PENYAKIT
1. Klien :…………
2. Keluarga : …………

E. POLA FUNGSIONAL KESEHATAN


1. Pola Manajemen Kesehatan-Persepsi Kesehatan
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.......................................................................................................
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2. Pola Metabolik-Nutrisi
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3. Pola Eleminasi
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4. Pola Aktivitas-Latihan
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5. Pola Istirahat-Tidur
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6. Pola Persepsi-Kognitif
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7. Pola Konsep Diri-Persepsi Diri


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8. Pola Hubungan-Peran
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9. Pola Reproduktif-Seksualitas
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10. Pola Toleransi Terhadap Stres-Koping


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11. Pola Keyakinan-Nilai


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F.PEMERIKSAAN FISIK
Keadaan umum :
 GCS : E..…….....….V.....................M...................
 Tingkat kesadaran : ………………….........................................
 Tanda – tanda vital : TD….............N….........RR….........T…......
 BB : ………….TB:………… LILA :………..

Head toe toe :


 Kepala
wajah :
Pucat ( )
Cloasma ( )
sklera :
konjungtiva :
pembesaran limphe node
pembesaran kelenjar tiroid :
telinga : ………………………………………
 Dada
Payudara
Areola :……………..
Putting : (menonjol / tidak )
Tanda dimpling / retraksi :…………………
Pengeluaran ASI : ………………..
Jantung : ……….
Paru : …………..
 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 : …………………..
 Genetalia dan perineum :
Kebersihan :……………
Pengeluaran :………………….
Karakteristik :……………..
Hasil VT : ……………………………………………………………….

Hemoroid :…………………
 Ekstremitas
Atas
Oedema :………………....................................................…
Varises :…………………....................................................
CRT :…………………....................................................
Bawah
Oedema :…………………....................................................
Varises :…………………....................................................
CRT :…………………....................................................
Refleks :……………….......................................................
G.DATA PENUNJANG
 Pemeriksaan Laboratorium :………………………..

 Pemeriksaan USG :………………………..

H.DIAGNOSA MEDIS

I.PENGOBATAN
KALA I
A. DATA FOKUS KALA I

B.ANALISA DATA KALA I


DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ..............................................................................................
2. ..............................................................................................
3. ..............................................................................................
4. ..............................................................................................
5. ..............................................................................................

II. RENCANA KEPERAWATAN KALA I


I. RENCANA KEPERAWATAN
No Tgl / jam Nomor Rencana Keperawatan
Diagnosa Tujuan Intervensi Rasional
IV. IMPLEMENTASI KALA I
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
V.EVALUASI KALA I
Tgl/Jam No Dx Evaluasi Hasil Paraf
KALA II
A. DATA FOKUS KALA II

B. ANALISA DATA KALA II


DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................

C. RENCANA KEPERAWATAN KALA II


No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
D. IMPLEMENTASI KALA II
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
E. EVALUASI KALA II

Tgl/Jam No Dx Evaluasi Hasil Paraf


KALA III
F. DATA FOKUS KALA III

G. ANALISA DATA KALA III


DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................
H. RENCANA KEPERAWATAN KALA III
No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
I. IMPLEMENTASI KALA III
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
J. EVALUASI KALA III
Tgl/Jam No Dx Evaluasi Hasil Paraf
KALA IV
A. DATA FOKUS KALA IV

B. ANALISA DATA KALA IV


DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................

B. RENCANA KEPERAWATAN KALA IV


No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
D. IMPLEMENTASI KALA IV
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
A. EVALUASI KALA IV

Tgl/Jam No Dx Evaluasi Hasil Paraf


Denpasar, Maret 2017

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(……………………........................….) (……………......................…………….)
NIP: NIM:

Clinical Teacher/CT 1

(……..…………….....................................................)
NIP:
FORMAT ASUHAN KEPERAWATAN BAYI BARU LAHIR
ASUHAN KEPERAWATAN PADA By..................
DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........

I PENGKAJIAN
i. IDENTITAS PASIEN
Nama : ............................................

Umur : ............................................

Nama Ayah-Ibu : ............................................

Umur : ............................................

Pendidikan : ............................................

Pekerjaan : ............................................

Status perkawinan : ............................................

Agama : ............................................

Suku : ............................................

Alamat : ............................................

No.CM : ............................................

Tanggal MRS : ............................................

Tanggal pengkajian : ............................................

Sumber informasi : ............................................


ii. RIWAYAT KELAHIRAN

No Tahun Jenis BB lahir Keadaan Komplikasi Jenis Ket


kelahiran kelamin bayi persalinan

iii. 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....

IV. 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 Gerakan Reaksi
reflex bereaksi sedikit melawan
Warna Biru/pucat Tubuh Kemerahan
kemerahan,
tangan dan
kaki biru

V. 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
o Inspeksi : .............................................................

o Palpasi : .............................................................

Leher
o Inspeksi : .............................................................

o Palpasi : .............................................................

Tubuh
o Warna :……………………………………………

o Lanugo :……………………………………………

o Vernix :……………………………………………

Dada
o Inspeksi : .................................................

o Palpasi : .................................................

o Perkusi : .................................................

o Auskultasi : …………..............................................

Abdomen
o Inspeksi :.............................................................

o Auskultasi : ............................................................

o Perkusi :.............................................................

o Palpasi : .............................................................

Punggung
o Keadaan punggung : ...............................................
o Fleksibilitas : ...............................................

o Tulang punggung : ...............................................

o Kelainan : ...............................................

Genetalia dan anus


o Laki-laki : ...............................................

o Perempuan : ..............................................

o Anus : ...............................................

o Mekonium : ...............................................

o Kelainan : ...............................................

Ekstremitas
o Atas : .............................................................

o Bawah : ............................................................

o Kelainan : .............................................................

o Pergerakan : ...........................................................

VI. STATUS NEUROLOGI


Pemeriksaan refleks : .................................................

VII. NUTRISI
ASI/PASI/Lain-lain
VIII. ELIMINASI
BAB pertama, tanggal ........................ Jam..................
BAK pertama, tanggal ........................ Jam..................

IX . DATA PENUNJANG
o Pemeriksaan Laboratorium :…………………………..

o Pemeriksaan Diagnostik :…………………………..

X. DIAGNOSA MEDIS

………………………………………………………………………………………………
………………………………………………………………………………………………

XI. PENGOBATAN
B. ANALISA DATA

DATA FOKUS ANALISIS MASALAH


DS : Analisis dengan pohon masalah

DO :
Diagnosa keperawatan berdasarkan prioritas :
1. ........................................

2. ........................................

3. ........................................

C. RENCANA KEPERAWATAN
IV. IMPLEMENTASI
Tgl/ No. Implementasi Respon Paraf/Nama
Jam Dx
V. EVALUASI

Tgl/Jam No Evaluasi Hasil Paraf


Dx
S=

O=

A=

P=
S=

O=

A=

P=
FORMAT ASUHAN KEPERAWATAN 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

D. RIWAYAT OBSTERTRI DAN GINEKOLOGI


a. Riwayat Menstruasi :
 Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : .................... Lamanya : .....................................
 Keluhan : .................................................................
 HPHT : .................................................................

b. Riwayat Pernikahan :
 Menikah : ....................kali Lama : ................. tahun.

c. Riwayat kelahiran, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak


No Tahun Umur Penyulit Jenis Penolong Penyulit Laser Infe Pedarah Jenis BB Pj
kehamilan asi ksi an kelam
in
d. Riwayat Keluarga Berencana :
 Akseptor KB : jenis .............. Lama : ..................
 Masalah : .................................................
 Rencana KB : .................................................

E. POLA FUNGSIONAL KESEHATAN


1. Pola Manajemen Kesehatan-Persepsi Kesehatan
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………
2. Pola Metabolik-Nutrisi
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

3. Pola Eleminasi
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

4. Pola Aktivitas-Latihan
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

5. Pola Istirahat-Tidur
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

6. Pola Persepsi-Kognitif
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
7. Pola Konsep Diri-Persepsi Diri
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

8. Pola Hubungan-Peran
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

9. Pola Reproduktif-Seksualitas
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

10. Pola Toleransi Terhadap Stres-Koping


………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

11. Pola Keyakinan-Nilai


………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………

F. PEMERIKSAAN FISIK
Keadaan umum
- GCS : ......................................
- Tingkat kesadaran : ......................................
- Tanda-tanda fital : TD ............. N .............. RR .............. T ...............
- BB : ................... TB : ............... LILA : ........
Head toe toe :
 Kepala
wajah : ..........................................................................
Pucat ( )
Cloasma ( )
sklera : ..........................................................................
konjungtiva : : ..........................................................................
pembesaran limphe node : ....................................................................
pembesaran kelenjar tiroid : ....................................................................

telinga : ………………………………………

 Dada
Payudara
Areola :…………….. Putting : (menonjol / tidak )
Tanda dimpling / retraksi :………………….
Pengeluaran ASI : ………………..
Jantung : ………. Paru: …………..

Abdomen :
o Linea : .................. ................... Satriae : ....................
Luka SC..............................................................
o Bising usus : .................
o TFU : ......................................
o Kontraksi : ......................................
o Diastasi rectus abdominis : ......................................

Genetalia
o Kebersihan : ......................................
o Lokhea : ............................... Krakteristik : ..........................
Perineum dan anus
o Perineum : REEDA .......................
o Hemoroid : ......................................

Ekstremitas :
Atas : ......................................
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Bawah
Oedema : ......................................
Varises : ......................................
CRT : ......................................
Tanda homan : ......................................
Pemeriksaan Reflek : ......................................

F.DATA PENUNJANG
 Pemeriksaan Laboratorium :

 Pemeriksaan radiologik :
G. PENGOBATAN

II. DIAGNOSA MEDIS

A. ANALISA DATA

DATA FOKUS ANALISIS MASALAH


B. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS :
1. ......................................................................................................................
2. ......................................................................................................................
3. .....................................................................................................................

III. RENCANA KEPERAWATAN

No Tgl / jam Nomor Rencana Keperawatan


Diagnosa Tujuan Intervensi Rasional
IV. IMPLEMENTASI

Tgl/Jam No.Dx Implementasi Respon Paraf/Nama


V. EVALUASI

Tgl/Jam No Dx Evaluasi Paraf


FORMAT ASUHAN KEPERAWATAN GINEKOLOGI

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 OBSTERTRI DAN GINOKOLOGI


a. Riwayat Menstruasi :
 Menarche : Umur Siklus : teratur ( ) tidak ( )
 Banyaknya: Lamanya :
 Keluhan:
 HPHT:
b. Riwayat Pernikahan :
 Menikah: kali Lama : tahun.
c. Riwayat kelahiran, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak


N Tahu Umur Penyu Jeni Penolo Penyu Las Infek Pedarah Jenis B P
o n kehamil lit s ng lit e si an kelam B j
an rasi in
d. Riwayat Keluarga Berencana :
 Akseptor KB : jenis Lama :
 Masalah :

 Rencana KB :

D. POLA FUNGSIONAL KESEHATAN


1. Pola Manajemen Kesehatan-Persepsi Kesehatan

2. Pola Metabolik-Nutrisi

3. Pola Eleminasi
4. Pola Aktivitas-Latihan

5. Pola Istirahat-Tidur

6. Pola Persepsi-Kognitif

7. Pola Konsep Diri-Persepsi Diri

8. Pola Hubungan-Peran

9. Pola Reproduktif-Seksualitas
10. Pola Toleransi Terhadap Stres-Koping

11. Pola Keyakinan-Nilai

E. PEMERIKSAAN FISIK
Keadaan umum
 GCS :
 Tingkat kesadaran :
 Tanda-tanda vital : TD: N: RR: T:
 BB : TB: LILA :
Head to toe
Kepala Wajah
o Inspeksi : .............................................................
o Palpasi : .............................................................

Leher
o Inspeksi : .............................................................
o Palpasi : .............................................................

Dada
o Inspeksi : .................................................
o Palpasi : .................................................
o Perkusi : .................................................
o Auskultasi : …………..............................................

Abdomen
o Inspeksi :.............................................................
o Auskultasi : ............................................................
o Perkusi :.............................................................
o Palpasi : .............................................................

Genetalia
 Kebersihan : ......................................
 Keputihan : .....................................

Perineum dan anus


 Perineum : .....................................
 Hemoroid : ......................................

Ekstremitas :
Atas : ......................................
 Oedema : ......................................
 Varises : ......................................
 CRT : ......................................

Bawah : ......................................
 Oedema : ......................................
 Varises : ......................................
 CRT : .......................................
 Pemeriksaan Reflek : ............................
F. DATA PENUNJANG
 Pemeriksaan Laboratorium:

 Pemeriksaan radiologik :

G. DIAGNOSA MEDIS

H. PENGOBATAN

II. ANALISA DATA


DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ........................................
2. ........................................
3. ........................................
III. RENCANA KEPERAWATAN
No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
IV. IMPLEMENTASI
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
V. EVALUASI
Tgl/Jam No Dx Evaluasi Hasil Paraf
Denpasar, 20…..
Mengetahui,
Pembimbing Klinik/ CI Mahasiswa

( ) ( )
NIP: NIM.

Clinical Teacher/CT

( )
NIP: