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

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

I. PENGKAJIAN
Tanggal masuk : ....................... Jam masuk : ......................
Ruang/Kelas : .......................
Pengkajian tanggal : ....................... Jam : .......................

A. IDENTITAS
Nama pasien : ........................ Nama suami pasien : ........................
Umur : ........................ Umur : ........................
Suku/Bangsa : ........................ Suku/Bangsa : ........................
Agama : ........................ Agama : ........................
Pendidikan : ........................ Pendidikan : ........................
Pekerjaan : ........................ Pekerjaan : ........................
Alamat : ........................ Alamat : ........................
Tanggal persalinan : ........................
No. Register : ........................

B. ALASAN DIRAWAT
1. Alasan masuk RS
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2. Keluhan utama
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3. Riwayat penyakit sebelumnya
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4. Riwayat penyakit keluarga
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C. RIWAYAT OBSTERTRI DAN GINEKOLOGI

1. Riwayat Menstruasi :
 Menarche : Umur .........................
 Siklus : teratur ( ) tidak ( )
 Banyaknya : ....................................
 Lamanya : .....................................
 Keluhan : ....................................
 HPHT : ....................................

2. Riwayat Pernikahan :
  Menikah : ....................kali
 Lama : ................. tahun.

3. Riwayat kelahiran, persalinan, nifas yang lalu :

N Jenis Cara lahir Tempat BB Penyulit Keadaan Umur
o kelamin persalinan dan lahir saat ini
penolong

4. Riwayat Keluarga Berencana :

 Akseptor KB : jenis ..............
 Lama : .......................
 Masalah : .......................
 Rencana KB : ........................

D. POLA FUNGSIONAL KESEHATAN

1. Pemeliharaan dan persepsi terhadap kesehatan
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2. Pola Nutrisi
a. Sebelum masuk RS
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b. Setelah masuk RS
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3. Pola eliminasi
a. Sebelum masuk RS
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b. Setelah masuk RS
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4. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/ minum
Mandi
Toileting
Berpakaian
Mobilisasi ditempat tidur
Berpindah
Ambulasi ROM
Keterangan :
1 : mandiri
2 : alat bantu
3 : dibantu orang lain
4 : dibantu orang lain dan alat
5 : tergantung total.

a. Sebelum masuk RS
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b. Setelah masuk RS
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5. Oksigensi
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6. Pola Tidur dan istrahat

a. Sebelum masuk RS
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b. Setelah masuk RS
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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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E. PEMERIKSAAN FISIK
1. Keadaan umum
 GCS : ......................................
 Tingkat kesadaran : ......................................
 Tanda-tanda vital :
TD : .............
N : ..............
RR : ..............
S : ...............
 BB : ...................
 TB : ...................
 LILA : ...................
2. Pemeriksaan Head to toe
a. Kepala Wajah
 Inspeksi :.............................................................
 Palpasi : : .............................................................

b. Leher
 Inspeksi :.............................................................
 Palpasi : : .............................................................

c. Dada
1) Jantung
 Inspeksi : ............................................................
 Palpasi : ............................................................
 Perkusi : .............................................................
 Auskultasi : ………….............................................

2) Paru-paru
 Inspeksi : ............................................................
 Palpasi : ...........................................................
 Perkusi : ............................................................
 Auskultasi : …………............................................

d. Abdomen :
 Linea : .............................................................
 Striae : . ...........................................................
 TFU : . ...........................................................
 Kontraksi : .............................................................
 Diastasi rectus abdominis : ..............................................
 Bising usus : .............................................................

e. Genetalia
 Kebersihan : .............................................................
 Lokhea : .............................................................
 Konsistensi : .............................................................
 Jumlah : ............................................................
 Bau : ............................................................

f. Perineum dan anus

 Perineum
 Keadaan : ............................................................
 Tanda REEDA : ............................................................
 Hemoroid : ............................................................

g. Ekstremitas :
1) Atas : ......................................
 Oedema : ......................................
 Varises : ......................................
 CRT : ......................................

2) Bawah
 Oedema : ......................................
  Varises : ......................................
 CRT : ......................................
 Tanda homan : ......................................
 Pemeriksaan Reflek: ......................................

F. DATA PENUNJANG
1. Pemeriksaan Laboratorium
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2. Pemeriksaan radiologik
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3. Pemeriksaan USG
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G. TERAPI MEDIS
1. Oral
2. Injeksi
3. Infus

II. ANALISA DATA

Data Etiologi Masalah

Diagnosa keperawatan berdasarkan prioritas:

1. ………………………………………………………………………………………
2. …………………………………………………………………………………………
I. RENCANA KEPERAWATAN
No Tanggal Diagnosa Rencana Keperawatan
Jam Keperawatan Tujuan Intervensi Keperawatan

II. IMPLEMENTASI
Tanggal No Diagnosa Implementasi Keperawatan Respon Pasien Paraf
Jam Keperawatan Nama

III. EVALUASI
Tanggal No Diagnosa Evaluasi Hasil Paraf
Jam Keperawatan Nama
S:
O:
A:
P:

………………., …………………..2021

Pembimbing Klinik/ CI Mahasiswa

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