ASUHAN KEPERAWATAN PADA Ny……………

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

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

B. DATA KESEHATAN
a. Keluhan Utama :
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b. Keluhan saat pengkajian :
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c. Riwayan keluhan ( kaji data dari mulai timbulnya keluhan sampai dengan
dilakukan asuhan keperawatan )
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C. RIWAYAT OBSTETRI DAN GINEKOLOGI

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

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

3. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak Ke Kehamilan Persalinan Komplikasi nifas Anak

No Thn Umur Penyulit jenis penolong Penyulit Laserasi infeksi Perdarahan Jenis BB Pj
kehamilan Kelamin

4. Riwayat kehamilan saat ini Status Obstetrikus :

a) G…A…P…A…H… UK.............minggu
b) TP : ….
c) ANC kehamilan sekarang :………..
Trimester I :…………………………………………………………
Trimester II : ………………………………………………………..
Trimester III : ……………………………………………………….
 5. Riwayat Keluarga Berencana :
 Akseptor KB : jenis .............. Lama : ..................
 Masalah : .......................

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

- 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 : ……………………………………………………………………

 Ekstremitas
Atas :
Oedema :…………………
Varises :…………………
CRT :…………………
 Bawah :

Oedema :…………………

Varises :…………………

CRT :…………………

Tanda hormon :…………………

Pemeriksaan Refleks :………………....

G. DATA PENUNJANG
 Pemeriksaan Laboratorium :
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 Pemeriksaan USG :
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H. DIAGNOSA MEDIS

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I. PENGOBATAN

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II. ANALISA DATA KALA I

DATA FOKUS ANALISIS MASALAH

 Diagnosa keperawatan berdasarkan prioritas :
1. .........................................................................................................................................
........................................................................................................................................
2. .........................................................................................................................................
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3. .........................................................................................................................................
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III. RENCANA KEPERAWATAN KALA I

No Tgl / jam No 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. ............................................................................................................................................
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C. RENCANA KEPERAWATAN KALA II

No Tgl / jam No Rencana Keperawatan

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. .............................................................................................................................................
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3. .............................................................................................................................................
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H. RENCANA KEPERAWATAN KALA III
No Tgl / No 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. .........................................................................................................................................
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3. .........................................................................................................................................
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C. RENCANA KEPERAWATAN KALA IV

No Tgl / jam No Rencana Keperawatan

Diagnosa Tujuan Intervensi Rasional
 D. IMPLEMENTASI KALA IV

Tgl/Jam No.Dx Implementasi Respon Paraf/Nama

 E. EVALUASI KALA IV

Tgl/Jam No Dx Evaluasi Hasil Paraf

 Gianyar, …………………….2020
Mengetahui
Pembimbing Klinik/ CI Mahasiswa

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

Clinical Teacher/CT 1

(……..………………………………)
NIP: