LAPORAN PRAKTIK KLINIK KEPERAWATAN DASAR

DI RUMAH SAKIT…………….........................

Oleh :

1. NamaMahasiswa NIM mahasiswa

2. NamaMahasiswa NIM mahasiswa
3. NamaMahasiswa NIM mahasiswa
4. NamaMahasiswa NIM mahasiswa

PROGRAM STUDI SARJANA KEPERAWATAN

STIKES WIDYAGAMA HUSADA
MALANG
2018
 LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA ………………. DENGAN

............................... DI ………………………….

Laporan Ini Disusun Untuk Memenuhi

Tugas PraktikKlinikKeperawatanDasar

Oleh:
NamaMahasiswa NIM Mahasiswa

Disetujui pada:

Hari : ..............................
Tanggal : ..............................

Pembimbing Institusi Pembimbing Lahan

Nama, Gelar Nama, Gelar

NIDN. NIP.

Kepala Ruang

Nama, Gelar
NIP
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 PENGKAJIAN

FORMAT PENGKAJIAN

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk :........... ............. Jam masuk :.........................

Ruang/kelas :........................ Kamar no :.........................
Pengkajian tanggal :......................... Jam pengkajian :.........................

I. Identitas
Nama klien :............................ Nama suami :.........................
Umur :...................... ...... Umur :.........................
Suku/bangsa :............................ Suku/bangsa :.........................
Agama :............................ Agama :.........................
Pendidikan :............................ Pendidikan :.........................
Pekerjaan :............................ Pekerjaan :.........................
Alamat :............................ Alamat :.........................
Status perkawinan :............................

II. Keluhan Utama

Saat MRS :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Saat pengkajian :
.........................................................................................................................................
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III. Riwayat Kesehatan

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 IV. Riwayat Pernikahan
Status pernikahan :......................................
Jika menikah :berapa kali..................lamanya....................usia...................

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

2. Riwayat Kehamilan, Persalinan, Nifas yang lalu

Anak ke Kehamilan Persalinan Komplikasi nifas Anak Keadaan

anak
sekarang
No Th UK Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan IK BB PI

3. Riwayat Hamil Ini

Taksiran Persalinan (TP) :.............................................
Keluhan :
a. Trimester I :..........................................................................................
b. Trimester II :..........................................................................................
c. Trimester III :..........................................................................................
Perawatan antenatal : di...................................berapa kali..................................
Gerakan janin :..........................................................................................
Tanda bahaya dan penyulit kehamilan :................................................................
Obat/jamu yang pernah dan sedang di konsumsi :...................................................
4. Riwayat Persalinan Sekarang
Tipe persalinan : spontan / bantuan..........................................................................
Tgl & jam persalinan :..........................................................................................
Lama persalinan : Kala I.............................jam
Kala II............................jam
Kala III ...........................jam
BB lahir anak :......................................................
Jenis kelamin anak :......................................................
Apgar score :......................................................
Jumlah perdarahan :......................................................
Data lain-lain
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

5. Riwayat Nifas
Tanggal...............................jam..........................................
Invulutio :
- TFU :.................................................................
- Kontraksi :......................................................
Lochea :
- Warna :.................................................................
- Jumlah :.................................................................
- Jenis :.................................................................
Laktasi :
- Kolostrum :............................................................
- ASI :.....................................................................
Keluhan lain :
...................................................................................................................................

6. Rencana Perawatan Bayi

a. Sendiri/orang tua/lain-lain..................................................................................
b. Kesanggupan dan pengetahuan dalam merawat bayi :
- Breast Care :..............................................
- Perineal Care :...........................................
 - Nutrisi :........................................................
- Senam nifas :................................................
- KB :.............................................................
- Menyusui :....................................................

7. Riwayat KB
Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan :...................................................
Sejak kapan menggunakan kontrasepsi :................................................................
Masalah yang terjadi :..........................................................................................

VI. Riwayat Kesehatan Keluarga

1. Keturunan kembar : ya / tidak
2. Penyakit menular / keturunan :.............................................................................
3. Genogram

VII. Riwayat Kesehatan yang lalu

Penyakit yang pernah di alami :...............................th....................................................
Pengobatan yang pernah di dapat :..................................................................................
Riwayat operasi yang pernah di alami (jenis, tempat dan waktu) :
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VIII. Riwayat Psikososial Spiritual
1. Komunikasi :.............................................................................................................
2. Keadaan emosional :
( ) kooperatif ( ) depresi ( ) agresif ( ) hipoaktif ( ) bingung ( ) menarik diri
( ) cemas ( ) marah ( ) hiperaktif ( ) gelisah
3. Hubungan dengan keluarga :
( ) akrab ( ) terganggu ( ) lainnya.........................................................................
4. Hubungan dengan orang lain :
( ) akrab ( ) terganggu ( ) lainnya.........................................................................
5. Proses berfikir :
( ) terarah ( ) bingung ( ) ilusi ( ) halusinasi
6. Ibadah / spiritual :
...................................................................................................................................
...................................................................................................................................

7. Respon ibu terhadap kondisi saat ini :.......................................................................

8. Dukungan keluarga :.................................................................................................
9. Pengambilan keputusan dalam keluarga :.................................................................
10. Beban kerja dan kegiatan sehari-hari :......................................................................
11. Tempat dan petugas yang diinginkan untuk bersalin :..............................................
12. Riwayat Psikososial Post Partum :
- Taking In :..........................................................................................
- Taking Hold :..........................................................................................
- Letting Go :..........................................................................................

IX. Pola Dasar Khusus

a. Pola Nutrisi
1) Frekuensi makan :...............................................................................................
2) Nafsu makan :.....................................................................................................
3) Jenis makanan :...................................................................................................
4) Makanan yang tidak disukai/alergi/pantangan :.................................................
b. Pola Eliminasi
BAK
1) Frekuensi :..........................kali
2) Warna :..........................
 3) Keluhan :.............................

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
:.....................................................................................................................
......................................................................................................................
......................................................................................................................
- 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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II. Data Penunjang

1. Laboratorium :...........................................................................................................
2. NST,CST :.................................................................................................................
3. USG :.........................................................................................................................
4. Rontgen :...................................................................................................................
5. Terapi yang di dapat :................................................................................................

III. Data Tambahan

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Kota...................
Pemeriksa

(...............................)
 ANALISA DATA

Nama Pasien : ........................................................

Diagnosa : ........................................................

MASALAH
NO DATA ETIOLOGI
KEPERAWATAN
 DAFTAR DIAGNOSA KEPERAWATAN

Nama Pasien : ........................................................

Diagnosa : ........................................................

No. Dx TANGGAL DIAGNOSA TANGGAL TANDA

MUNCUL KEPERAWATAN TERATASI TANGAN

.
 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

Nama Pasien : ........................................................

Diagnosa : ........................................................

No. Dx. TTD &

Tgl Jam Tindakan Keperawatan Respon Klien Nama
Kep Terang
 EVALUASI
Hari/ No
Tanda
Tanggal/ Dx Evaluasi
Tangan
Jam

S:
...................................................................................
...................................................................................
O:
NOC:
Score
Indikator
Awl Tgt Akr

A: Masalah sesuai dengan NOC sudah / belum teratasi

P: Intervensi dihentikan / dilanjutkan dan didelegasikan
kepada perawat dinas ……… :
1. NIC :
………………………………………………
……….
2. NIC :
………………………………………………
……….
*Coret yang tidak perlu
 CATATAN PERKEMBANGAN
NAMA KLIEN : ......................................... TANGGAL : .........................................
DX. MEDIS : ......................................... RUANG : .........................................
NO HARI/TGL JAM DIAGNOSA IMPLEMENTASI EVALUASI
KEPERAWATAN
S:

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 :

I. Tujuan Instruksional Umum

Setelah dilakukan penyuluhan kesehatan
…………………………………………………………………………………………
…………………..……......…………………………………………….

II. Tujuan Instruksional Khusus

Setelah mengikuti pendidikan kesehatan selama ……. menit, diharapkan
semua peserta mampu:
1. ………………….
2. ………………….

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)

VII. Setting Tempat

VIII. Koordinasi
Moderator :
Penyaji :
Notulen :

IX. Evaluasi
Struktur :
Proses :
Hasil :
X. Lampiran Materi Penyuluhan

Berita acara dan daftar hadir