ASUHAN KEPERAWATAN PADA ...........

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

PENGKAJIAN
Pengkajian dilakukan tangal…………………. Di ruang ……… RSUD ………………… dengan
teknik wawancara, pemeriksaan fisik dan dokumentasi.

1. IDENTITAS PASIEN PENANGGUNG/SUAMI

Nama : .................................................. .....................................................

Umur : .................................................... ....................................................
Pendidikan : .................................................... ....................................................
Pekerjaan : .................................................... ....................................................
Staus Perkawinan: .................................................. ....................................................
Agama : .................................................... ....................................................
Suku : .................................................... ....................................................
Alamat : ..................................................... ....................................................
No. CM : ......................................................
Tanggal MRS : ........................................................
Tanggal Pengkajian: ....................................................
Sumber informasi: ....................................................

2. ALASAN DIRAWAT
A. Keluhan Utama (saat MRS dan sekarang):
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B. Keluhan Utama Saat Pengkajian
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3. RIWAYAT OBSTETRI DAN GINEKOLOGI

A. Riwayat Menstruasi:
 Menarche : Siklus :
 Banyaknya : Lamanya :
 Keluhan :
  HPHT :
 TP :
B. Riwayat Pernikahan:
 Menikah : Lama :
C. Riwayat Kontrasepsi
Akseptor KB : Jenis: Lama :
D. Riwayat Kehamilan, Persalinan, Nifas yang Lalu:

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

Umur Pen Perd
Penolon Peny Lase Infe Jenis
No Tahun Kehami yak Jenis arah BB PJ
g ulit rasi ksi Kelamin
lan it an

E. Riwayat Kehamilan,Persalinan yang sekarang:

1) Riwayat Kehamilan
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2) Riwayat Persalinan
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Diagnosa Medis:
Terapi saat Pengkajian:
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4. POLA FUNGSIONAL KESEHATAN

1. Imunisasi
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2. Riwayat alergi
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3. Riwayat Kecelakaan
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4. Riwayat dirawat di RS
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5. Riwayat pemakaian obat
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5. RIWAYAT PENYAKIT KELUARGA
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6. POLA KEBIASAAN
a. Bernafas
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b. Makan dan minum
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c. Eliminasi
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d. Gerak dan aktivitas
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e. Istirahat dan tidur
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f. Kebersihan Diri
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g. Pengaturan Suhu Tubuh
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h. Rasa Nyaman
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i. Rasa Aman
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j. Data Sosial
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k. Prestasi dan Produktivitas
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l. Rekreasi
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m. Belajar
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n. Ibadah
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7. PEMERIKSAAN FISIK
a. Keadaan umum
1) Kesadaran : …………………………………………………………………….
2) Bangun Tubuh : …………………………………………………………………….
3) Postur Tubuh : …………………………………………………………………….
4) Cara Berjalan : …………………………………………………………………….
5) Gerak Motorik : …………………………………………………………………….
6) Keadaan Kulit : …………………………………………………………………….
7) Tanda-Tanda Vital : TD: …… S: …… N:…… RR:…….
8) BB sebelum hamil : …………………………………………………………………….
9) BB saat hamil : …………………………………………………………………….
 10) TB : ……………………………. LILA: ……………………………
b. Head to toe
1) Kepala, wajah:
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2) Mata
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3) Hidung
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4) Telinga
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5) Mulut
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6) Leher
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7) Thorax
Payudara:
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Jantung:
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Paru:
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8) Abdomen
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9) Genetalia dan perineum
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10) Anus
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11) Ekstremitas
Atas
Oedema : ………………………………………………………………………...
Varies : ………………………………………………………………………...
CRT : ………………………………………………………………………...
Bawah
Oedema : ………………………………………………………………………...
Varies : ………………………………………………………………………...
CRT : ………………………………………………………………………...

7. DATA PENUNJANG
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KALA I
A. ANALISA DATA KALA 1

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas:

1. ……………………………...................................................................................................
2. ...............................................................................................................................................
3. ...............................................................................................................................................
 B. RENCANA KEPERAWATAN KALA 1

NO RENCANA KEPERAWATAN
DX
TUJUAN INTERVENSI RASIONAL
 C. IMPLEMENTASI KALA 1

TGL/ NO EVALUASI/ PARAF/

IMPLEMENTASI
JAM DX RESPON KLIEN NAMA
 D. EVALUASI KALA I

TGL/ NO EVALUASI HASIL PARAF

JAM DX
KALA II
A. ANALISA DATA KALA II

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas:

4. ……………………………...................................................................................................
5. ...............................................................................................................................................
6. ...............................................................................................................................................
 B. RENCANA KEPERAWATAN KALA II

NO RENCANA KEPERAWATAN
DX
TUJUAN INTERVENSI RASIONAL
 C. IMPLEMENTASI KALA II

TGL/ NO EVALUASI/ PARAF/

IMPLEMENTASI
JAM DX RESPON KLIEN NAMA
 D. EVALUASI KALA II

TGL/ NO EVALUASI HASIL PARAF

JAM DX
KALA III
A. ANALISA DATA KALA III

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas:

7. ……………………………...................................................................................................
8. ...............................................................................................................................................
9. ...............................................................................................................................................
 B. RENCANA KEPERAWATAN KALA III

NO RENCANA KEPERAWATAN
DX
TUJUAN INTERVENSI RASIONAL
 C. IMPLEMENTASI KALA III

TGL/ NO EVALUASI/ PARAF/

IMPLEMENTASI
JAM DX RESPON KLIEN NAMA
 D. EVALUASI KALA III

TGL/ NO EVALUASI HASIL PARAF

JAM DX
KALA IV
A. ANALISA DATA KALA IV

DATA ETIOLOGI MASALAH

Diagnosa keperawatan berdasarkan prioritas:

10. ……………………………...................................................................................................
11. ...............................................................................................................................................
12. ...............................................................................................................................................
 B. RENCANA KEPERAWATAN KALA IV

NO RENCANA KEPERAWATAN
DX
TUJUAN INTERVENSI RASIONAL
 C. IMPLEMENTASI KALA IV

TGL/ NO EVALUASI/ PARAF/

IMPLEMENTASI
JAM DX RESPON KLIEN NAMA
 D. EVALUASI KALA IV

TGL/ NO EVALUASI HASIL PARAF

JAM DX