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

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

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

II. RIWAYAT MASUK RUMAH SAKIT

Keluhan Utama (saat MRS dan sekarang)
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Riwayat persalinan sekarang
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 Keadaan bayi sekarang
Berat badan = .........................
Panjang badan = .........................
Lingkar kepala = .........................
Lingkar dada = .........................
Lingkar perut = .........................
dll = .........................

III. RIWAYAT OBSTETRI DAN GINEKOLOGI

A. Riwayat menstruasi:
 Menarche : umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : ................... Lamanya : .............................
 Keluhan : ...................

B. Riwayat pernikahan:
 Menikah : .......... kali Lama : .......... tahun

C. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak
Kehamilan Persalinan Komplikasi nifas Anak
ke
Umur
Je- Peno- Lase- Perda- Jenis
No Thn kehamil- Penyulit Penyulit Infeksi BB Pj
nis long rasi rahan kelamin
an

D. Riwayat Keluarga Berencana :

 Akseptor KB : jenis ............. Lama : .............
 Masalah : ......................
 Rencana KB : ......................
IV. POLA FUNGSIONAL KESEHATAN
1. Pemeliharaan dan persepsi terhadap kesehatan
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2. Nutrisi/ metabolic
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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.
5. Oksigenasi
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6. Pola tidur dan istirahat
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7. Pola perseptual
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8. Pola persepsi diri
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9. Pola seksual dan reproduksi
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10. Pola peran-hubungan
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 11. Pola manajemen koping stress
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12. Sistem nilai dan keyakinan
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V. PEMERIKSAAN FISIK
Keadaan umum
 GCS : ................................................
 Tingkat kesadaran : ................................................
 Tanda-tanda vital : TD = .................. N = .......... RR = .......... T = ..........
 BB : ........................... TB : .......... LILA :........

Head to toe
Kepala Wajah :
 Inspeksi :
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 Palpasi :
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Mata:
 Inspeksi :
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 Palpasi :
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Leher :
 Inspeksi :
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 Palpasi :
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Dada:
 Payudara
Inspeksi :
 Areola............. Puting : (menonjol/tidak)
 Tanda dimpling/ retraksi : ...........................
Palpasi :
 Pengeluaran ASI................. Adanya nodul: ………………
Perkusi :
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 Jantung
Inspeksi :
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Palpasi :
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Perkusi :
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 Auskultasi :
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 Paru
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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Abdomen :
 Inspeksi : Linea: ................ Striae: ................. Luka SC: ……….
 Auskultasi : Bising Usus: .......................
 Palpasi :
TFU : .................
Kontraksi : .................
Diastasis rectus abdominis : ..........................
 Perkusi :
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Genetalia dan Perineum:

 Kebersihan : ....................................................
 Lokhea : .................................................... Karakteristik : ..........................
 Perineum :
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Anus :
 Hemoroid : ....................................................

Ekstremitas:
 Atas :
Oedema : ........................
Varises : ........................
CRT : ........................
Kekuatan Otot : .......................
Tonus : .......................
 Bawah :
Oedema : .......................
Varises : .......................
CRT : .......................
Tanda homan : .......................
Pemeriksaan Reflek : .....................
Kekuatan Otot : .......................
Tonus : .......................

VI. DATA PENUNJANG

 Pemeriksaan Laboratorium :
Tgl.
Komponen Hasil Satuan Nilai Normal Intepretasi
No.
  Pemeriksaan Radiologik :
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VII. DIAGNOSA MEDIS
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VIII. PENGOBATAN
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B. ANALISA DATA
DATA ETIOLOGI MASALAH
Diagnosa keperawatan berdasarkan prioritas:
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C. RENCANA KEPERAWATAN
RENCANA KEPERAWATAN
NO. DIAGNOSA
TUJUAN INTERVENSI RASIONAL
D. IMPLEMENTASI
TGL/ NO
IMPLEMENTASI EVALUASI/RESPON KLIEN PARAF/NAMA
JAM DX
E. EVALUASI/ CATATAN PERKEMBANGAN
TGL/ NO
EVALUASI
JAM DX
 Denpasar, ............................ 20.…

Mengetahui,
Pembimbing klinik/CI Mahasiswa

(........................................) (............................................)
NIP. NIM.

Clinical Teacher / CT

(...............................................)
NIP.