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 Keadaan Komplikasi Jenis Ket

kelahiran kelamin lahir 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
1. …………………………………………………………………………………………
…………………………………………………………………………………………
2. …………………………………………………………………………………………
…………………………………………………………………………………………
3. …………………………………………………………………………………………
…………………………………………………………………………………………

xi. PENGOBATAN
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

b. ANALISA DATA
DATA FOKUS ANALISIS MASALAH
DS :
DO :
 Diagnosa keperawatan berdasarkan prioritas :
1. ........................................................................................................................................
........................................................................................................................................
2. ........................................................................................................................................
........................................................................................................................................
3. ........................................................................................................................................
........................................................................................................................................
c. 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 Hasil Paraf
 Denpasar, …………………….20….
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(…………………………………….) (……………..……………….)
NIP: NIM:
Clinical Teacher/CT

(……..…………..……………)
NIP