RESUME KEPERAWATAN ANTE NATAL

PADA NY “ ………….. “
DI KLINIK KANDUNGAN

RUMAH SAKIT TK. III DR. R. SOETARTO

STASE KEPERAWATAN MATERNITAS

DISUSUN OLEH :

NAMA : Adriana Bodu Lori

NIM : PN.20.08.31

PRODI ILMU KEPERAWATAN DAN NERS

SEKOLAH TINNGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2021
 RESUME KEPERAWATAN ANTE NATAL
PADA NY “ ………….. “
DI KLINIK KANDUNGAN
RUMAH SAKIT TK. III DR. R. SOETARTO
STASE KEPERAWATAN MATERNITAS

Resume keperawatan ini telah dibaca, diperiksa pada

Hari/tanggal :

Pembimbing Klinik Mahasiswa Parktikan

( ………………………….. ) ( Adriana Bodu Lori )

Mengetahui
Pembimbing Akademik

( ……………………………………….. )
 RESUME KEPERAWATAN ANTE NATAL
PADA NY “ ………….. “
DI KLINIK KANDUNGAN
RUMAH SAKIT TK. III DR. R. SOETARTO

Nama mahasiswa :Adriana Bodu Lori

NIM : PN.20.08.31
Tempat praktek : Klinik Kandungan Rumah Sakit TK.III dr. R. Soetarto
Tanggal Pengkajian :

I. IDENTITAS PASIEN
Nama :..................................................................................................................
Umur :..................................................................................................................
Status perkawinan: ..............................................................................................
Agama :................................................................................................................
Suku :...................................................................................................................
Pendidikan :.........................................................................................................
Pekerjaan :...........................................................................................................
Tanggal MRS :.....................................................................................................
No. Rekam Medis :..............................................................................................

Nama suami/ penanggung jawab:........................................................................

Umur:...................................................................................................................
Alamat:................................................................................................................
Pekerjaan:............................................................................................................
Pendidikan:..........................................................................................................

Status Obstetri : G:……. P:..…… A:….. Ah:

HPMT:.................................................................................................................
HPL:....................................................................................................................
Keadaan Umum:
 Kesadaran:
 BB : ….... kg (kenaikan BB selama hamil: ….… kg); TB: ……
cm
 Tanda vital : Nadi: ………x/menit Suhu badan: ………...…0 C
 RR : ………x/menit TD : ………….. mmHg
II. DATA SUBYEKTIF
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III. DATA OBJEKTIF

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IV. ANALISA DATA
Tgl/ jam Data Masalah Etiologi
V. PRIORITAS MASALAH (DIAGNOSA KEPERAWATAN/MASALAH KOLABORASI)
a. ……………………………………………………………………………………………………

b. ……………………………………………………………………………………………………

c. ……………………………………………………………………………………………………

d. ....................................................................................................................................
 INTERVENSI KEPERAWATAN

Nama Klien/ umur : .............................................. No RM/ Ruang : …………………………… Diagnosa Medis : ………
Hari/tgl Diagnosa
jam Keperawatan/ Tujuan (NOC) Intervensi (NIC)
Masalah Kolaborasi

Indikator A T
CATATAN PERKEMBANGAN
Nama Klien/ umur : .............................. No RM/ Ruang : …………………………. Diagnosa Medis : ……………………
Diagnosa Keperawatan Hari/ tgl Paraf
Implementasi Evaluasi
jam Nama
S:

O:
A:

Indikator A T C

P: