Format Analisa Tindakan Keperawatan

Nama :........................................................................
NIM :........................................................................
Jenis Tindakan :........................................................................

1. Identitas pasien
Nama :........................................................................
Umur :........................................................................
Jenis Kelamin :........................................................................
Pekerjaan :........................................................................
Agama :........................................................................
Tanggal masuk :........................................................................
Alasan masuk :........................................................................
Dx Medis :........................................................................

2. Tahap Persiapan

Persiapan pasien :.................................................................................................

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..................................................................................................
..........................

Persiapan :.................................................................................................
lingkungan ..................................................................................................
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Persiapan Alat :.................................................................................................

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..............
3. Tahap Pelaksanaan

No Pelaksanaan

4. Tahap Akhir

Terminasi :......................................................................................................
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..........................................................................

Evaluasi :......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
............................................................................

Dokumentasi :......................................................................................................
.............................................................................
5. Analisa Materi Tindakan

Pengertian Tindakan :..........................................................................................

...........................................................................................
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...........................................................................................
...........................................................................................
........................................................

Tujuan Tindakan :..........................................................................................

...........................................................................................
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6. Evaluasi Hasil Tindakan

Hasil Tindakan :...................................................................................................

....................................................................................................
....................................................................................................
.................................................................

7. Evaluasi Diri

Evalauasi Diri :...................................................................................................

....................................................................................................
....................................................................................................
...............................................................

Singaraja,..........................2019
Mahasiswa,

..................................................
NIM.......................................
 Menyetujui,
Clinical Instruktur (CI) Clinical Teacher (CT)
Ruang ................................................. STIKES Buleleng

............................................................ .........................................................
NIP....................................................... NIK...............................................
 PENGKAJIAN ANTENATAL

Nama mahasiswa : .........................................................

NIM : .........................................................

Tempat Praktek/ Ruang : .........................................................

I. Identitas Klien
Nama : .........................................................

Umur : .........................................................

No. Reg : .........................................................

Pendidikan : .........................................................

Pekerjaan : .........................................................

Alamat : .........................................................

Suku : .........................................................

Agama : .........................................................

Tanggal MRS : .........................................................

Tanggal Pengkajian : .........................................................

Identitas Penanggung Jawab

Nama : .........................................................

Umur : .........................................................

Pendidikan : .........................................................

Pekerjaan : .........................................................

Alamat : .........................................................

Suku : .........................................................

Agama : .........................................................

Hubungan dengan : .........................................................

klien
II. Integritas ego, Persepsi dan Harapan klien sehubungan dengan kehamilan
1. Mengapa ibu datang ke klinik?
Jelaskan :..................................................................................................
.
...................................................................................................
.

2. Apakah kehamilan ini menimbulkan perubahan terhadap kehidupan sehari-hari? Bila

Ya, Bagaimana?
Jelaskan :...................................................................................................
....................................................................................................
……………………………………………………………………………………………….
……………………………………………………………………………………………….

3. Perasaan klien atau suami tentang kehamilan :

Jelaskan :...................................................................................................
....................................................................................................
………………………………………………………………………………………………..

4. Melaporkan faktor stress :

Masalah :............................................................................................
keuangan .............................................................................................

Gaya hidup :............................................................................................

.............................................................................................

Perubahan :............................................................................................
terakhir .............................................................................................

5. Cara mengatasi stress

Jelaskan :...................................................................................................
....................................................................................................
……………………………………………………………………………………………….

6. Harapan yang ibu inginkan selama masa kehamilan

Jelaskan :...................................................................................................
....................................................................................................
……………………………………………………………………………………………….

7. Ibu tinggal dengan siapa

Jelaskan :...................................................................................................
....................................................................................................
 8. Status emosional
Jelaskan :..................................................................................................
.
...................................................................................................
.

9. Respon psikologis yang teramati

Jelaskan :...................................................................................................
....................................................................................................
………………………………………………………………………………………………..

10. Siapa orang yang terpenting bagi ibu

Jelaskan :..................................................................................................
.
...................................................................................................
.

11. Apakah suami (orang terdekat) mau menemani untuk datang ke klinik?
Ya : ................................
Tidak :……………………………………………………………………………………………………….

12. Rencana melahirkan dimana?

Jelaskan :..................................................................................................
.
...................................................................................................
.

13. Apakah ibu merencanakan untuk menyusui bayinya?

Ya : ................................
Tidak :……………………………………………………………………………………………………….

III. Kebutuhan Dasar Khusus

1. Aktivitas/ Istirahat
1) Aktivitas/ Hobi kebiasaan
Jelaskan :...........................................................................................
............................................................................................

2) Pembatasan karena kehamilan/ kondisi

Jelaskan :...........................................................................................
............................................................................................

3) Adakah gangguan untuk istirahat-tidur selama kehamilan? Ya/ Tidak, Bila Ya

Jelaskan :...........................................................................................
 ............................................................................................

4) Status mental (mis : menarik diri/ letargik)

Jelaskan :...........................................................................................
............................................................................................

5) Pengkajian neuromuskular
Massa/ :........................................................................................
Tonus otot .........................................................................................

Postur :........................................................................................
........................................................................................

Tremor :........................................................................................
.........................................................................................

Rentang :........................................................................................
Pergerakan .........................................................................................
Sendi

Kekuatan :........................................................................................
.........................................................................................

Deformitas :........................................................................................
........................................................................................

2. Sirkulasi
1. Riwayat
Peningkatan TD :...................................................................
....................................................................

Masalah jantung :...................................................................

....................................................................

Edema pergelangan kaki :...................................................................

....................................................................

Flebitis :...................................................................
....................................................................
 Penyembuhan lambat :...................................................................
....................................................................

2. Ekstremitas
Kebas :........................................................................................
.........................................................................................

Kesemutan :........................................................................................
.........................................................................................

3. Batu/ hemoptisis
Jelaskan :........................................................................................
.........................................................................................

4. Perubahan frekuensi, jumlah urin

Jelaskan :........................................................................................
.........................................................................................

5. TD (Ka & Ki) :

Berdiri :........................................................................................
.........................................................................................

Duduk :........................................................................................
.........................................................................................

Berbaring :........................................................................................
.........................................................................................

6. Nadi perifer
Radialis :........................................................................................
.........................................................................................

Dorsalis :........................................................................................
.........................................................................................

IVD :........................................................................................
.........................................................................................

7. Bunyi jantung
 Kecepatan :........................................................................................
.........................................................................................

Irama :........................................................................................
.........................................................................................

Kualitas :........................................................................................
.........................................................................................

Rub/mur :........................................................................................
.........................................................................................

8. Bunyi nafas
Rub/murmu :........................................................................................
r .........................................................................................

9. Ekstremitas suhu
Warna :.............................................................................
..............................................................................

Pengisian kapiler :.............................................................................

..............................................................................

Tanda homan :.............................................................................

..............................................................................

Varises :.............................................................................
..............................................................................

Kuku(abnormal) :.............................................................................
..............................................................................

10. Warna/ sianosis seluruhnya

Membran :..........................................................................................
mukosa ..........................................................................................

Bibir :..........................................................................................
..........................................................................................
 Dasar :..........................................................................................
..........................................................................................

Kuku :..........................................................................................
..........................................................................................

Konjungtiva :..........................................................................................
..........................................................................................

Sklera :..........................................................................................
..........................................................................................

Diaforesis :..........................................................................................
..........................................................................................

3. Eliminasi
1. Pola usus biasanya
Penggunaan :......................................................................................
laksatif .......................................................................................

Karakter :......................................................................................
feses .......................................................................................

Defekasi :......................................................................................
terakhir .......................................................................................

Perdarahan :......................................................................................
.......................................................................................

Hemoroid :......................................................................................
.......................................................................................

Diare :......................................................................................
.......................................................................................

2. Pola Berkemih Kebiasaan

Inkontinensia :...................................................................
....................................................................
 Dorongan :...................................................................
....................................................................

Frekuensi :...................................................................
....................................................................

Retensi :...................................................................
....................................................................

Karakter urin :...................................................................

....................................................................

Nyeri/rasa terbakar/ :...................................................................

kesulitan ....................................................................

Berkemih :...................................................................
....................................................................

Riwayat penyakit ginjal/ :...................................................................

kandung kemih ....................................................................

Penggunaan diuretik :...................................................................

....................................................................

3. Palpasi abdomen
Lunak/keras :...................................................................
....................................................................

Masa yang dapat :...................................................................

dipalpasi ....................................................................

ukuran/lingkar :...................................................................
....................................................................

Bising usus :...................................................................

....................................................................

Hemaroid :...................................................................
....................................................................
 Palpasi kandung kemih :...................................................................
....................................................................

Uranilisis :...................................................................
....................................................................

Albuminuria :...................................................................
....................................................................

Gilikosuria :...................................................................
....................................................................

Darah samar :...................................................................

....................................................................

Darah samar feses :...................................................................

....................................................................

4. Makanan/ Cairan
1. Diet kebiasaan (jenis)
Jumlah Makanan :...................................................................
....................................................................

Makanan/masukan :...................................................................
terakhir ....................................................................

Pola diet :...................................................................

....................................................................

Kehilangan nafsu makan :...................................................................

....................................................................

Mual/muntah :...................................................................
....................................................................

Disebabkan :...................................................................
oleh/dikurangi oleh ....................................................................

Alergi/intoleransi :...................................................................
 makanan ....................................................................

2. Masalah mengunyah/menelan
Gigi gerigi :..................................................................
.
...................................................................
.

3. Rata-rata berat badan tidak hamil

Berat badan saat ini :...................................................................
....................................................................

Pola berat badan :...................................................................

....................................................................

Penambahan/penuruna :...................................................................
n ....................................................................

4. Penggunaan diuretik
Jelaskan :..............................................................................................
...............................................................................................
...............................................................................................

5. Berat badan saat ini

Tinggi badan :...................................................................

Bentuk tubuh :...................................................................

Turgor kulit :...................................................................

....................................................................

Kelembaban/ :...................................................................
kekeringan membran ....................................................................
mukosa

6. Hernia/massa
Jelaskan :..............................................................................................
...............................................................................................
...............................................................................................

7. Edema
Jelaskan :.........................................................................................
 ..........................................................................................

Periorbital :.........................................................................................
..........................................................................................

Saklar :.........................................................................................
..........................................................................................

Distensi :.........................................................................................
vena ..........................................................................................
jugularis

8. Pembesaran tiroid
Jelaskan :.........................................................................................
..........................................................................................

9. Bau mulut
Jelaskan :.........................................................................................
..........................................................................................

10. Bising usus

Jelaskan :.........................................................................................
..........................................................................................

11. Bunyi panas

Jelaskan :.........................................................................................
..........................................................................................

12. Skrining diabetik

Jelaskan :.........................................................................................
..........................................................................................

13. Hb/Ht (anemia)

Jelaskan :.........................................................................................
..........................................................................................

5. Aktivitas Kehidupan Sehari-hari

1. Aktivitas kehidupan sehari-hari : Mandi/tergantung
Jelaskan :.........................................................................................
..........................................................................................

2. Penampilan umum
 Cara :.....................................................................................
berpakaian ......................................................................................

Kebiasaan :.....................................................................................
pribadi ......................................................................................

Bau badan :.....................................................................................

......................................................................................

Kondisi kulit :.....................................................................................

kepala ......................................................................................

Adanya :.....................................................................................
kutu ......................................................................................

6. Neurosensori
1. Serangan pingsan/ pusing
Jelaskan :.........................................................................................
..........................................................................................

2. Sakit kepala
Lokasi :.........................................................................................
..........................................................................................

Frekuensi :.....................................................................................
......................................................................................

kessemutan/ :.....................................................................................
kebas/ ......................................................................................
kelemahan
(lokasi)

3. Stroke (efek residu)

Jelaskan :.........................................................................................
..........................................................................................

4. Kejang
Jelaskan :...................................................................................
....................................................................................

Cara :...................................................................................
pengontrolan ....................................................................................
 5. Mata
Kehilangan :...................................................................................
penglihatan ....................................................................................

Periksaan :...................................................................................
terakhir ....................................................................................

6. Telinga :
Kehilangan :...................................................................................
pendengaran ....................................................................................

Pemeriksaan :...................................................................................
terakhir ....................................................................................

7. Kacamata
Kontak :...................................................................................
....................................................................................

Alat bantu :...................................................................................

dengar ....................................................................................

8. Epistaksis
Indra :...................................................................................
penciuman ....................................................................................

9. Status mental
Berorientasi/ :...................................................................................
disorientasi ....................................................................................
(diuraikan)

10. Pola/ kerusakan bicara biasanya

Jelaskan :...................................................................................
....................................................................................

7. Nyeri Ketidaknyamanan
1. Nyeri
Lokasi :...................................................................................
....................................................................................

Intensitas :...................................................................................
(0-10 pada 10 ....................................................................................
paling berat)

Frekuensi :...................................................................................
 ....................................................................................

Kualitas :...................................................................................
....................................................................................

Durasi :...................................................................................
....................................................................................

Faktor :...................................................................................
pencetus ....................................................................................

Bagaimana :...................................................................................
hilangnya ....................................................................................

Garis yang :...................................................................................

berhubungan ....................................................................................

2. Wajah meringis

0/0 1/2 2/4 3/6 4/8 5/10

Tidak Nyeri Sedikit Nyeri Nyeri Nyeri Lebih Sangat Nyeri Nyeri Hebat
Berat

Area yang :...................................................................................

dipengaruhi ....................................................................................

Respon :...................................................................................
emosional ....................................................................................

Fokus :...................................................................................
menyempit ....................................................................................

8. Pernapasan
1. Dispnea
Berhubungan :...................................................................................
 dengan ....................................................................................

Batuk/sputum :...................................................................................
....................................................................................

2. Riwayat
Bronkitis :...................................................................................
....................................................................................

Asma :...................................................................................
....................................................................................

TBS :...................................................................................
....................................................................................

Emfisema :...................................................................................
....................................................................................

Pneumonia :...................................................................................
berulang ....................................................................................

3. Perokok
Pneumonia :.............................Pak/hari
berulang

Selama (tahun) :...................................................................................

....................................................................................

Pengguna alat :...................................................................................

bantu ....................................................................................
pernapasan

Oksigen :...................................................................................
....................................................................................

4. Pernafasan
Frekuensi :...................................................................................
....................................................................................

Kedalaman :...................................................................................
....................................................................................

Kualitas :...................................................................................
....................................................................................
 5. Bunyi nafas
Jelaskan :...................................................................................
....................................................................................

6. Karakteristik sputum
Jelaskan :...................................................................................
....................................................................................

7. Hasil sinar X dada

Jelaskan :...................................................................................
....................................................................................

9. Keamanan
1. Alergi/ sensitivitas
Alergi/ :...................................................................................
sensitivitas ....................................................................................

Reaksi :...................................................................................
....................................................................................

2. Perubahan sebelumnya dari sistem imun

Jelaskan :...................................................................................
....................................................................................

Penyebab :...................................................................................
....................................................................................

3. Riwayat penyakit hubungan kelamin/infeksi ginekologis (tanggal/jenis)

Jelaskan :...................................................................................
....................................................................................

Perilaku risiko :...................................................................................

tinggi ....................................................................................

Tes :...................................................................................
....................................................................................

4. Riwayat cedera kecelakaan:

Fraktur/ :...................................................................................
dislokasi ....................................................................................
 penyakit fisik :...................................................................................
....................................................................................

artritis/sendi :...................................................................................
tidak stabil ....................................................................................

masalah :...................................................................................
punggung ....................................................................................

5. Kerusakan penglihatan
Jelaskan :...................................................................................
....................................................................................

Pendengaran :...................................................................................
....................................................................................

6. Kekuatan umum
Jelaskan :...................................................................................
....................................................................................

Tonus :...................................................................................
....................................................................................

Cara berjalan :...................................................................................

....................................................................................

Rentang gerak :...................................................................................

....................................................................................

Parestesia/ :...................................................................................
paralisis ....................................................................................

7. Janin
Frekuensi :...................................................................................
jantung ....................................................................................

Lokasi :...................................................................................
...................................................................................
 Metode :...................................................................................
auskultasi ....................................................................................

Berat badan :...................................................................................

dasar ....................................................................................

Perkiraan :...................................................................................
gestasi ....................................................................................

Gerakan :...................................................................................
....................................................................................

Ballotemen :...................................................................................
....................................................................................

8. Hasil kultur, servikal/ rektal

Jelaskan :...................................................................................
....................................................................................

Tes sistem :...................................................................................

imun ....................................................................................

Golongan :...................................................................................
darah ....................................................................................

maternal :...................................................................................
....................................................................................

Skrining :...................................................................................
....................................................................................

Serologi :...................................................................................
....................................................................................

Sifilis :...................................................................................
....................................................................................

Sel sabit :...................................................................................

....................................................................................
 Rubela :...................................................................................
....................................................................................

Hepatitis :...................................................................................
....................................................................................

HIV :...................................................................................
....................................................................................

10. Seksualitas (Komponen Interaksi Sosial)

1. Masalah seksual
Jelaskan :...................................................................................
....................................................................................

2. Menarche
Lamanya :...................................................................................
....................................................................................

Siklus :...................................................................................
....................................................................................

Durasi :...................................................................................
....................................................................................

3. Hari pertama menstruasi terakhir

Jumlah :...................................................................................
....................................................................................

4. Keyakinan klien tentang kapan terjadi konsepsi

Jelaskan :...................................................................................
....................................................................................

5. Perkiraan tanggal kelahiran

Jelaskan :...................................................................................
...................................................................................

6. Praktik pemeriksaan payudara sendiri (Y/T)

Jelaskan :...................................................................................
....................................................................................

7. PAP Smear terakhir

Jelaskan :...................................................................................
 ....................................................................................

Hasil :...................................................................................
....................................................................................

8. Metode kontrasepsi terbaru

Jelaskan :...................................................................................
....................................................................................

9. Status obstetrik :
Pemeriksaan luar

Tinggi FU :................................. cm atas symp,

atau .............................................................................
.......

Lingk. Perut ...................................cm

Let. Anak :...................................................................................

....................................................................................

His :...................................................................................
....................................................................................

BJA :...................................................................................
....................................................................................

Hal lain :...................................................................................

....................................................................................

Pemeriksaan dalam (jika perlu)

Jelaskan :...................................................................................
....................................................................................

Pemeriksaan panggul (jika perlu)

Jelaskan :...................................................................................
....................................................................................

Ukuran :...................................................................................
panggul luar
 ....................................................................................

Dist spin :...................................................................................

....................................................................................

Dist Crist :...................................................................................

....................................................................................

Dist Tub :...................................................................................

....................................................................................

Lingkar :...................................................................................
panggul ....................................................................................

Ukuran :...................................................................................
panggul dalam ....................................................................................

Promont :...................................................................................
....................................................................................

Cd :.......................................................................cm

CV :.......................................................................cm

Riwayat Kehamilan/ Persalinan yang lalu :

Keadaan kehamilan, Keadaan anak

No
Perkw persalinan, keguguran, Tgl.Lahir & Lahir (BB, JK, jika
Uru
No mulai haid, kehamilan penolong hidup mati pada
t
ektopik, nifas dll umur)
 10. Komplikasi
Jelaskan :...................................................................................
....................................................................................

11. Prognosis untuk melahirkan

Jelaskan :...................................................................................
....................................................................................

12. Pemeriksaan payudara

Jelaskan :...................................................................................
....................................................................................

Puting :...................................................................................
....................................................................................

13. Tes kehamilan

Jelaskan :...................................................................................
....................................................................................

Tes serologi :...................................................................................

....................................................................................

11. Interaksi Sosial

1. Status perkawinan............
Jelaskan :..................................................................................

Peran dalam :...................................................................................

struktur ....................................................................................
keluarga
 2. Keluarga besar
Jelaskan :...................................................................................
....................................................................................

Orang :...................................................................................
pendukung lain ....................................................................................

Frekuensi :...................................................................................
kontak sosial ....................................................................................

3. Masalah/ stress
Jelaskan :...................................................................................
....................................................................................

Perilaku koping :...................................................................................

....................................................................................

4. Rencana untuk periode intra/ pascanatal

Jelaskan :...................................................................................
....................................................................................

5. Komunikasi verbal/ non verbal dengan orang terdekat/ keluarga

Jelaskan :...................................................................................
....................................................................................

6. Pola interaksi keluarga ( perilaku)

Jelaskan :...................................................................................
....................................................................................

12. Penyuluhan/ pembelajaran

1. Tingkat pendidikan ibu/ayah

Jelaskan :...................................................................................
....................................................................................

Pekerjaan :...................................................................................
....................................................................................

2. Latar belakang etnik/ budaya

Jelaskan :...................................................................................
....................................................................................
 Keyakinan kesehatan/ praktik khusus (termasuk faktor religius)

Jelaskan :...................................................................................
....................................................................................

3. Faktor- faktor resiko keluarga ( menandakan hubungan )

Jelaskan :...................................................................................
....................................................................................

Penyakit :...................................................................................
diabetes ....................................................................................

TBC :...................................................................................
....................................................................................

Hipertensi :...................................................................................
....................................................................................

Epilepsi :...................................................................................
....................................................................................

Penyakit :...................................................................................
jantung ....................................................................................

Stroke :...................................................................................
....................................................................................

Penyakit ginjal :...................................................................................

...................................................................................

Kanker :...................................................................................
....................................................................................

Kelainan darah :...................................................................................

....................................................................................

Penyakit :...................................................................................
mental ....................................................................................

Masalah :...................................................................................
 genetik
(kongenital) ....................................................................................

Kelahiran :...................................................................................
sesaria ....................................................................................

Kelahiran :...................................................................................
multiple ....................................................................................

4. Obat yang diresepkan

Obat :...................................................................................
....................................................................................

Dosis :...................................................................................
....................................................................................

Waktu :...................................................................................
....................................................................................

Penggunaan :...................................................................................
terakhir ....................................................................................

Tujuan :...................................................................................
....................................................................................

5. Obat yang tidak diresepkan

Obat bebas :...................................................................................

....................................................................................

Obat jalanan :...................................................................................

....................................................................................

Penggunaan :...................................................................................
alkohol ....................................................................................
(jumlah/
frekuensi)
 Tembakau :...................................................................................
....................................................................................

6. Keluhan/ gejala penyerta dari kehamilan

Efek pada gaya :...................................................................................

hidup ....................................................................................

Adaptasi yang :...................................................................................

dibuat ....................................................................................

7. Penyakit yang relevan dan/atau perawatan di rumah sakit/pembedahan

Jelaskan :...................................................................................
....................................................................................

8. Rangkuman Hasil Pengkajian

Masalah :

1) .............................................................................................................................
.......................................................................................................................
2) .............................................................................................................................
.......................................................................................................................
3) .............................................................................................................................
.......................................................................................................................
4) .............................................................................................................................
.......................................................................................................................
5) .............................................................................................................................
.......................................................................................................................

9. Rencana Kunjungan Rumah

Jelaskan :........................................................................................
.........................................................................................
.........................................................................................
 PENGKAJIAN INTRANATAL

Nama mahasiswa :.........................................................................

Tanggal pengkajian :.........................................................................

RS/Ruangan :.........................................................................

1. Data Umum
Inisial klien :................................................(…...th)

Pekerjaan :...................................................

Agama :...................................................

Pendidikan terakhir :...................................................

Alamat :...................................................

Nama Suami :..................................... (.... .th)

Pekerjaan :...................................................

Agama :...................................................

Pendidikan terakhir :...................................................

Suku bangsa :...................................................

 Status perkawinan :...................................................

Alamat :......................................................................................
.
.......................................................................................
.

2. Data Umum Kesehatan

1) TB/BB .................cm/……………kg
2) BB sebelum hamil :..................kg
3) Masalah kesehatan khusus
Jelaskan :......................................................................................................
.
.......................................................................................................
.

4) Obat-obatan
Jelaskan :......................................................................................................
.
.......................................................................................................
.

5) Alergi (obat/makanan/bafian tertentu)

Jelaskan :......................................................................................................
.
.......................................................................................................
.

6) Diet khusus
Jelaskan :......................................................................................................
.
.......................................................................................................

7) Alat Bantu yang digunakan :gigi tiruan/kacamata/lensakontak/alat dengar )*

8) Lain-lain
Jelaskan :......................................................................................................
.
.......................................................................................................
.

9) Frekuensi BAK
Jelaskan :......................................................................................................
.
.......................................................................................................
.

10) Frekuensi BAB

Jelaskan :......................................................................................................
 .
.......................................................................................................
.

11) Kebiasaan waktu tidur

Jelaskan :......................................................................................................
.
.......................................................................................................
.

3. Data Umum Kebidanan

1) Kehamilan sekarang direncanakan : ya / tidak

2) Status obstetrik : G…..... P........ A…..... H........ minggu

3) HPHT :......................................

4) Taksiran partus :......................................

5) Jumlah anak di rumah

No Jenis Kelamin Cara lahir BB lahir Keadaan Umur

6) Mengikuti kelas prenatal: (ya/tidak)

Jelaskan :......................................................................................................
.
.......................................................................................................
.

7) Jumlah kunjungan ANC pada kehamilan ini

Jelaskan :......................................................................................................
 .
.......................................................................................................
.

8) Masalah kehamilan yang lalu

Jelaskan :......................................................................................................
.
.......................................................................................................
.

9) Masalah kehamilan sekarang

Jelaskan :......................................................................................................
.
.......................................................................................................
.

10) Rencana KB
Jelaskan :......................................................................................................
.
.......................................................................................................
.

11) Makanan bayi sebelumnya :

ASI/PASI/lainnya :........................................................................................

12) Pelajaran yang diinginkan saat ini : (lingkari)

Relaksasi/pernafasan/manfaat ASI/cara memberi minum botol/senam nifas/metoda
KB/perawatan perineum/perawatan payudara, lain-lain

Jelaskan :....................................................................................................
.....................................................................................................

13) Setelah bayi lahir, siapa yang diharapkan membantu : suami/teman/orangtua )*

14) Masalah dalam persalinan yang lalu

Jelaskan :......................................................................................................
.
.......................................................................................................
.

4. Riwayat persalinan sekarang

1) Mulai persalinan (kontraksi/pengeluaran pervaginam) :
tgl/jam

Jelaskan :......................................................................................................
.
.......................................................................................................
.

2) Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan)

Jelaskan :......................................................................................................
.
.......................................................................................................
.

3) Frekuensi, kualitas, dan keteraturan denyut jantung janin

Jelaskan :......................................................................................................
.
.......................................................................................................
.

4) Pemeriksaan fisik:

Kenaikan BB selama kehamilan :...............kg

Tanda vital: TD:…. mmHg, Nadi:...... x/menit, Suhu:....... oC, Pernapasan:....... x/menit

Kepala dan leher (normal/tidak)

Jelaskan :..................................................................................................
.................................................................................................

Jantung

Jelaskan :....................................................................................................
.....................................................................................................

Paru-paru

Jelaskan :....................................................................................................
.....................................................................................................

Payudara

Jelaskan :....................................................................................................
.....................................................................................................
 Abdomen (secara umum dan pemeriksaan obstetrk)

Jelaskan :..................................................................................................
.................................................................................................

Kontraksi :..................................................................................................
.................................................................................................

DJJ :..................................................................................................
.................................................................................................

Ekstremitas:

(edema/tidak)

Jelaskan :..................................................................................................
.................................................................................................

Refleks

Jelaskan :..................................................................................................
.................................................................................................

5) Pemeriksaan dalam pertama :

Jam :.............................................................

Oleh :.............................................................

Hasil :

Jelaskan :..................................................................................................
.................................................................................................

6) Ketuban (utuh/pecah), jika sudah pecah

Tgl/Jam :...................................................

Warna :...................................................

7) Laboratorium
Jelaskan :..................................................................................................
.................................................................................................

5. Data Psikososial
1. Penghasilan keluarga setiap bulan

Jelaskan :..................................................................................................
.................................................................................................
2. Perasaan klien terhadap kehamilan sekarang

Jelaskan :..................................................................................................
.................................................................................................

3. Perasaan suami terhadap kehamilan sekarang

Jelaskan :..................................................................................................
.................................................................................................

4. Jelaskan respon sibling terhadap kehamilan sekarang

Jelaskan :..................................................................................................
.................................................................................................
 LAPORAN PERSALINAN

Nama mahasiswa : .........................................................

NIM : .........................................................

Tempat Praktek/ Ruang : .........................................................

Nama klien : .........................................................

Umur : .........................................................

RS/ Klinik Bersalin : .........................................................

Tanggal Masuk : .........................................................

1. ANAMNESE
1) Alasan dirawat
Jelaskan :.......................................................................................................
........................................................................................................
........................................................................................................

2) Haid
Menarrche :.................................................................................................
..................................................................................................

Siklus :.................................................................................................
..................................................................................................

Lamanya :.................................................................................................
haid ..................................................................................................

Banyaknya :.................................................................................................
..................................................................................................

Dysmenora :.................................................................................................
..................................................................................................

Haid :.................................................................................................
terakhir ..................................................................................................

3) Perkawinan
Haid :.................................................................... kali
 terakhir

Dengan :.................................................................................................
suami ..................................................................................................
sekarang

4) Riwayat kehamilan, dan persalinan dan nifas yang lalu

No At/P/i/Ab/E BBL Cara Penolong L/P Umur H/M

Lahir

5) Tindakan operasi yang pernah dilakukan

Jelaskan :.......................................................................................................
........................................................................................................
........................................................................................................

6) Kehamilan sekarang
Haid terakhir :...............................................................................................
................................................................................................

Taksiran :...............................................................................................
persalinan ................................................................................................

Pengawasan Ya/ Tidak

kehamilan Bila ya, dimana.......................................................................
...............................................................................................

7) Riwayat kehamilan sampai sekarang

Jelaskan :.......................................................................................................
........................................................................................................
........................................................................................................
8) Keadaan umum
Tanda vital TD :.......................mmHg

N :.......................x/mnt

T :.......................oC

RR :.......................x/mnt

Status :............................................................................................
antropometri .............................................................................................

2. STATUS OBSTETRIKUS
1) Pemeriksaan luar
Tinggi fundus :............................................................................................
uteri .............................................................................................

Letak anak :............................................................................................

.............................................................................................

Punggung :............................................................................................
.............................................................................................

Denyut jantung :...................... /menit

anak

His :............................................................................................
.............................................................................................

Lain-lain :............................................................................................
.............................................................................................

2) Pemeriksaan dalam (tanggal.................................................................)

Jelaskan :.......................................................................................................
........................................................................................................
........................................................................................................

3) Pemeriksaan panggul dalam

Jelaskan :.......................................................................................................
........................................................................................................
 ........................................................................................................

3. PEMERIKSAAN LABORATORIUM
Darah Lengkap / Urologi

Tanggal :........................................................

Hasil :

Rontgen / radiologi

Tanggal :........................................................

Hasil :
CT Scan

Tanggal :........................................................

Hasil :
4. DIAGNOSE
1. :..................................................................................................................
.................................................................................................................

2. :..................................................................................................................
.................................................................................................................

3. :..................................................................................................................
.................................................................................................................

4. :..................................................................................................................
.................................................................................................................

5. :..................................................................................................................
.................................................................................................................

5. LAPORAN PERSALINAN
1. Observasi (Tanggal......................................................................................)

Jam His Interval Lamanya BJA Intensitas VT

2. Proses persalinan (tanggal.......................................................................)
Jelaskan :........................................................................................................
.........................................................................................................

3. Bimbingan pada klien

Kala I
1. Mulai persalinan :
Tanggal :...................................................................................................
....................................................................................................

Jam :...................................................................................................
....................................................................................................

2. Tanda dan gejala

Jelaskan :...................................................................................................
 ....................................................................................................

3. Tanda- tanda vital

Jelaskan :...................................................................................................
....................................................................................................

4. Lama kala I
Jam :...................................................................................................
....................................................................................................

Menit :...................................................................................................
....................................................................................................

detik :...................................................................................................
....................................................................................................

5. Keadaan psikososial
Jelaskan :...................................................................................................
....................................................................................................

6. Kebutuhan khusu klien

Jelaskan :...................................................................................................
....................................................................................................

7. Tindakan
Jelaskan :...................................................................................................
....................................................................................................

8. Pengobatan
Jelaskan :...................................................................................................
....................................................................................................

9. Diagnosa Keperawatan
1) ....................................................................................................................................
....................................................................................................................................
........
10. Intervensi
Tujuan dan Kriteria Hasil Intervensi Paraf

11. Implementasi
Implementasi Evaluasi Paraf
Kala II
1. Kala II mulai

Tanggal :...................................................................................................
....................................................................................................

Jam :...................................................................................................
....................................................................................................

2. Lama Kala II

Jam :...................................................................................................
....................................................................................................

Menit :...................................................................................................
....................................................................................................

detik :...................................................................................................
....................................................................................................

3. Tanda gejala

Jelaskan :...................................................................................................
....................................................................................................

4. Kesadaran psikososial

Jelaskan :...................................................................................................
....................................................................................................

5. Tindakan

Jelaskan :...................................................................................................
....................................................................................................

6. Diagnosa Keperawatan
1) ....................................................................................................................................
..............................................................................................................................
7. Intervensi
Tujuan dan Kriteria Hasil Intervensi Paraf
12. Implementasi

Implementasi Evaluasi Paraf

Kala III

Keadaan bayi:

1. Bayi lahir jam

Jelaskan :...................................................................................................
....................................................................................................

2. Nilai apgar

Menit 1 :...................................................................................................
....................................................................................................

Menit 5 :...................................................................................................
....................................................................................................

3. Perineum : ( ) utuh ( ) episiotomi ( ) rupture

4. Nonding ibu dan bayi

Jelaskan :...................................................................................................
....................................................................................................

5. Tanda-tanda vital
Tanda vital TD :.......................mmHg

N :.......................x/mnt

T :.......................oC

RR :.......................x/mnt

6. Pengobatan

Jelaskan :...................................................................................................
 ....................................................................................................

7. Diagnosa Keperawatan
1) ....................................................................................................................................
..............................................................................................

8. Intervensi
Tujuan dan Kriteria Hasil Intervensi Paraf
13. Implementasi
Implementasi Evaluasi Paraf
Kala IV dan bimbingan pada klien :

1. Mulai jam
Jelaskan :...................................................................................................
....................................................................................................

2. Tanda-tanda vital
Jelaskan :...................................................................................................
....................................................................................................

3. Keadaan uterus
Jelaskan :...................................................................................................
....................................................................................................

4. Perdarahan
Jelaskan :...................................................................................................
....................................................................................................

5. Bonding ibu dan bayi

Jelaskan :...................................................................................................
....................................................................................................
6. Tindakan
Jelaskan :...................................................................................................
....................................................................................................

7. Diagnosa Keperawatan
1) ....................................................................................................................................
..............................................................................................

8. Intervensi
Tujuan dan Kriteria Hasil Intervensi Paraf
14. Implementasi
Implementasi Evaluasi Paraf
6. PEURPERIUM
Uterus Tinggi
Tgl Lactasi Lochea Jahitan BAB BAK
Fundus/ kontraksi
 7. BAYI
1. Bayi lahir tanggal/ jam
Jelaskan :...................................................................................................
....................................................................................................

2. Jenis kelamin
Jelaskan :...................................................................................................
....................................................................................................

3. Nilai apgar
Jelaskan :...................................................................................................
....................................................................................................

4. BB / PB Bayi
BB :.......................gram

PB :.......................cm

5. Karakteristik bayi
Jelaskan :...................................................................................................
....................................................................................................

6. Lingkar kepala :.................................cm

7. Kaput Suksedaneum ( ) Chepalhematon ( )
O
8. Suhu :........... C
9. Anus : berlobang/ tertutup
10. Perawatan tali pusat
Jelaskan
:...................................................................................................
....................................................................................................

11. Perawatan mata

12.
Jelaskan
:...................................................................................................
....................................................................................................

Tgl

Suhu

Berat Badan
Panjang

Cacat

BAB

BAK

M
 CATATAN PERSALINAN

Tanggal :………../………/……… Penolong Persalinan :................

Kala I :
 Partogram melewati garis waspada
 Ketuban: ............................................................................................................
 Lain-lain, sebutkan:……….................................................................................
Penatalaksanaan yang dilakukan untuk masalah tersebut :…….......................
Bagaimana hasilnya? ......................................................................
Kala II :
Lama Kala II: ....................... menit.
Episiotomi :  tidak  ya, indikasi : ...........................
Pendamping pada saat persalinan :  suami  keluarga  teman  dukun  tidak ada
Gawat janin :  miringkan ibu ke sisi kiri  minta ibu menarik napas  Episiotomi
Distosia bahu :  Manuver Me Robert  ibu merangkak  Lainnya :.......................
Lain-lain, sebutkan :.................................................................................................
Penatalaksanaan yang dilakukan untuk masalah tersebut :....................................
Bagaimana hasilnya ? .............................................................................................
Kala III :
Lama Kala III :.......................... menit.
Jumlah pendarahan ...............................ml.
a. Pemberian Oksitosin 10 U im < 2 menit?ya tidak, alasan...........................
Pemberian ulang Oksitosin(2x)?  ya alasan.....................................................
b. Penegangau tali pusat terkendali ?ya tidak, alasan....................................
c. Mesase fiwdus uteri?  ya tidak, alasan………………………..........................
Laserar Perieum, derajat .........................................................................................
Tindakan :  penjahitan dengan/tanpa (*) anestesi
Plasenta tidak lahir > 30 menit :  Mengeluarkan secara manual  Merujuk
 Tindakan lain:
Atom Uteri :  kompresi bimanual intema. metil ergometrin 0,2 mg im  oksitosin drip
Lain-lain, sebutkan :.................................................................................................
Penatalaksanaan yang dilakukan untuk masalah tersebut : ...................................
Bagaimana hasilnya?...............................................................................................
BAYI BARU LAHIR :
Berat badan :............ gram, Panjang .......... cm, jenis kelamin : L/P (*). nilai
APGAR......../.......
Pemberian ASI < 1 jam  ya tidak, alasan...........................................
Bayi lahir pucat/biru/lemas :  mengeringkan  menghangatkan bebaskan jalan napas
 stimulasi/rangsang taktil  Lain-lain sebutkan..................................................
 Cacat bawaan, sebutkan :.....................................................................................
 hipotermi
 Lain-lain sebutkan :...............................................................................................
Penatalaksanaan yang dilakukan untuk masalah tersebut :....................................
 Bagaimana hasilnya ?............................................................................

PENGKAJIAN POST PARTUM

I. Identitas Klien
Nama :...................................................................

Umur :...................................................................

Suku :...................................................................

Agama :...................................................................

Pendidikan :...................................................................

Pekerjaan :...................................................................

Alamat :...................................................................

No. Reg :...................................................................

Tanggal MRS :...................................................................

Tgl Pengkajian :...................................................................

II. Identitas Penanggung Jawab

Nama :...................................................................

Umur :...................................................................

Suku :...................................................................

Agama :...................................................................

Pendidikan :...................................................................

Pekerjaan :...................................................................

Alamat :...................................................................

Hub dengan px :...................................................................

III. RiwayatKesehatan Saat Ini

1. Keluhan utama saat MRS
Jelaskan :...................................................................................................
....................................................................................................
 2. Keluhan saat pengkajian
Jelaskan :...................................................................................................
....................................................................................................

3. Riwayat dirawat
Jelaskan :...................................................................................................
....................................................................................................

4. Riwayat kehamilan, Persalinan, Nifas sekarang

1) Riwayat kehamilan
Jelaskan :............................................................................................
.............................................................................................

2) Riwayat persalinan
Jelaskan :..........................................................................................
...........................................................................................

3) Riwayat Nifas
Jelaskan :..........................................................................................
...........................................................................................

IV. Riwayat Kesehatan Dahulu

1. Riwayat penyakit masa lalu
Jelaskan :...................................................................................................
....................................................................................................

2. Riwayat kesehatan keluarga

Jelaskan :...................................................................................................
....................................................................................................

(Genogram 3 generasi)

Keterangan:
 3. Riwayat kehamilan, Persalinan, Nifas Dahulu
4. N Cara
At/P/i/Ab/E BBL Penolong L/P Umur H/M
o Lahir

Jelaskan :...................................................................................................
....................................................................................................

5. Riwayat Obstetri dahulu

Jelaskan :...................................................................................................
....................................................................................................

V. KebutuhanDasar Khusus
1. Aktivitas/ Istirahat
1) Aktivitas tidur sebelum awitan persalinan
Jelaskan :............................................................................................
.............................................................................................

2) Lama Persalinan
Jelaskan :............................................................................................
.............................................................................................

3) Status Mental (mis : euphoria,menarik diri, letargi)

Jelaskan :............................................................................................
.............................................................................................
2. Sirkulasi
 1).TD :...........................mmHg
Nadi :...........................x/mnt
2). Ekstremitas
Suhu :.....................................................
Warna :.....................................................
Tanda :....................................................
Hodman
3). Kehilangan darah selama proses persalinan
Jelaskan :........................................................................................
.........................................................................................
3. Eliminasi
1) Waktu terakhir berkemih
Jelaskan :............................................................................................
.............................................................................................

2) Defekasi terakhir
Jelaskan :............................................................................................
.............................................................................................

3) Adanya hemoroid
Jelaskan :............................................................................................
.............................................................................................

4) Palpasi kandung kemih

Jelaskan :............................................................................................
.............................................................................................

5) Adanya kateter
Jelaskan :..........................................................................................
...........................................................................................

warna :..........................................................................................
urin ...........................................................................................

6) Bising usus
Jelaskan :...........................................................................................
.
............................................................................................
.
4. Makanan/ cairan
1) Masukan oral terakhir
Jelaskan :............................................................................................
.............................................................................................

2) Permintaan khusus
Jelaskan :............................................................................................
.............................................................................................
 3) Mual/ Muntah
Jelaskan :............................................................................................
.............................................................................................

4) Turgor kulit
Jelaskan :............................................................................................
.............................................................................................

5) Edema :
Kaki :............................................................................................
.............................................................................................
Sakrum :............................................................................................
.............................................................................................

Tangan :............................................................................................
.............................................................................................

Wajah :............................................................................................
.............................................................................................
6) Penampilan lidah
Jelaskan :........................................................................................
.........................................................................................

Membrane :........................................................................................
mukosa .........................................................................................

5. Neurosensori
1) Sensasi ekstremitas bawah
Jelaskan :........................................................................................
.........................................................................................

2) Gerakan ekstremitas bawah

Jelaskan :........................................................................................
.........................................................................................

3) Reflek tendon dalam

Jelaskan :........................................................................................
.........................................................................................

6. Nyeri/ ketidaknyamanan
Lokasi :...................................................................................
....................................................................................

Intensitas :...................................................................................
(0-10 pada 10 ....................................................................................
paling berat)
 Frekuensi :...................................................................................
....................................................................................

Kualitas :...................................................................................
....................................................................................

Durasi :...................................................................................
....................................................................................

Faktor :...................................................................................
pencetus ....................................................................................
Bagaimana :...................................................................................
hilangnya ....................................................................................

Garis yang :...................................................................................

berhubungan ....................................................................................

0/0 1/2 2/4 3/6 4/8 5/10

Tidak Sedikit Nyeri Nyeri Sangat Nyeri

Nyeri Nyeri Lebih Nyeri Hebat
Berat

7. Keamanan
1) Waktu rentang gerak
Jelaskan :........................................................................................
.........................................................................................

2) Masalah/tindakan pengobatan obstetric intra partum

Jelaskan :........................................................................................
.........................................................................................

3) Transfusi darah
Jelaskan :........................................................................................
.........................................................................................
8. Seksualitas
1) Fundus
Tinggi :........................................................................................
.........................................................................................

Posisi :........................................................................................
 .........................................................................................

Kontraksi :........................................................................................
.........................................................................................
2) Lochea :
Warna :........................................................................................
.........................................................................................

Aliran :........................................................................................
.........................................................................................

Adanya :........................................................................................
bekuan .........................................................................................
3) Perineum
Keadaan :........................................................................................
episiotom .........................................................................................
i
4) Payudara
Lunak :........................................................................................
.........................................................................................

Keras :........................................................................................
.........................................................................................

Putting :........................................................................................
.........................................................................................

Kolostrum :........................................................................................
.........................................................................................
9. Integritas ego dan Interaksi Sosial
1) Ekspresi perasaan
Jelaskan :........................................................................................
.........................................................................................

2) Realitas pengalaman persalinan/ kelahiran dibandingkan dengan harapan

tentang diri sendiri
Jelaskan :........................................................................................
.........................................................................................
3) Reaksi emosional
Penerimaan :......................................................................................
terhadap .......................................................................................
bayi

Konsep diri :......................................................................................

.......................................................................................

Penerimaan :......................................................................................
 keluarga .......................................................................................

10. Penyuluhan/ Pembelajaran

1) Pilihan pemberian makan bayi
Jelaskan :........................................................................................
.........................................................................................

2) Respon terhadap interaksi pemberian makan awal

Jelaskan :........................................................................................
.........................................................................................

3) Imunisasi
Jelaskan :........................................................................................
.........................................................................................
4) Perawatan bayi
Jelaskan :........................................................................................
.........................................................................................

5) Perawatan kebersihan diri

Jelaskan :........................................................................................
.........................................................................................

6) Keluarga berencana
Jelaskan :........................................................................................
.........................................................................................
VI.PemeriksaanFisik
1. Keadaan umum
Kesadaran :...................................................................................
GCS E :........... V :........... M :...........
Tanda vital TD :..........................mmHg
S :..........................oC
N :..........................x/mnt
RR :.......................... x/mnt

2. Kepala-leher

Inspeksi :....................................................................................
.....................................................................................
Kepala Palpasi :....................................................................................
.....................................................................................

Inspeksi :....................................................................................
.....................................................................................
Mata Palpasi :....................................................................................
.....................................................................................

Hidung Inspeksi :....................................................................................

 .....................................................................................
Palpasi :....................................................................................
.....................................................................................

Inspeksi :....................................................................................
.....................................................................................
Telinga Palpasi :....................................................................................
.....................................................................................

Inspeksi :....................................................................................
.....................................................................................
Mulut Palpasi :....................................................................................
.....................................................................................

Inspeksi :....................................................................................
.....................................................................................
Leher
Palpasi :....................................................................................
.....................................................................................

3. Thorax dan dada

Paru/ Inspeksi :................................................................................
dada .................................................................................
Palpasi :................................................................................
.................................................................................
Perkusi :................................................................................
.................................................................................
Auskultasi :................................................................................
.................................................................................

Jantung Inspeksi :................................................................................

.................................................................................
Palpasi :................................................................................
.................................................................................
Auskultasi :................................................................................
.................................................................................

Pemeriksaan payudara/ mammae

Inspeksi :................................................................................
.................................................................................
Palpasi :................................................................................
.................................................................................

4. Abdomen
Inspeksi :.................................................................................................
..................................................................................................
Auskultasi :.................................................................................................
..................................................................................................
 Palpasi :.................................................................................................
..................................................................................................
Perkusi :.................................................................................................
..................................................................................................

5. Pemeriksaan genetalia
Vulva Inspeksi :................................................................................
.................................................................................
Palpasi :................................................................................
.................................................................................

Perineum Inspeksi :................................................................................

.................................................................................
Palpasi :................................................................................
Vagina Inspeksi :................................................................................
.................................................................................
Palpasi :................................................................................
.................................................................................

Anus Inspeksi :................................................................................

.................................................................................
Palpasi :................................................................................
.................................................................................

Uretra Inspeksi :................................................................................

.................................................................................

6. Pemeriksaan ekstremitas
Simetrisitas Inspeksi :..........................................................................
...........................................................................
Kekuatan Jelaskan :..........................................................
otot ..........................................................................
Edema Inspeksi :..........................................................................
...........................................................................
Varises Inspeksi :..........................................................................
...........................................................................

7. Pemeriksaan integumen
Inspeksi :.................................................................................................
..................................................................................................

Palpasi :.................................................................................................
..................................................................................................

8. Pemeriksaan Penunjang
Darah Lengkap / Urologi
Tanggal :........................................................
 Hasil :

Rontgen / radiologi / USG

Tanggal :........................................................
Hasil :

CT Scan
Tanggal :........................................................
Hasil :

VI. Terapi
 No Nama obat Dosis

ASUHAN KEPERAWATAN KESEHATAN JIWA PADA KLIEN.........................

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

RUMAH SAKIT JIWA PROPINSI BALI DI BANGLI

TANGGAL....................................

I. Pengkajian
Pengkajian dilakukan pada tanggal.................................di ruang.............. RSJ
Propinsi Bali, dengan sumber data yaitu dari klien, perawat ruangan, catatan medik,
pemeriksaan fisik dan observasi.

1. Identitas Pasien
Ruang rawat :....................................................................................

Initial :....................................................................................

Umur :....................................................................................

Pekerjaan :....................................................................................

Tanggal masuk :....................................................................................

No R.M :....................................................................................

Status :....................................................................................

Pendidikan :....................................................................................

2. Alasan Masuk
a) Keluhan Utama Saat MRS
 Jelaskan :.............................................................................................................
..............................................................................................................
..

b) Keluhan Utama Saat Pengkajian

Jelaskan :.............................................................................................................
..............................................................................................................
..

c) Riwayat Penyakit
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
......

3. Faktor Predisposisi
1) Pernah mengalami gangguan jiwa masa lalu
 Ya
 Tidak
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
....

2) Pengobatan sebelumnya?
 Berhasil
 Kurang berhasil
 Tidak berhasil
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...
3) Penolakan Dari Lingkungan
 Ya
 Tidak
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

4) Trauma
Usia
Trauma Pelaku Korban Saksi
(th)

Aniaya Fisik

Aniaya Seksual

Penolakan

Kekerasan dalam keluarga

Tindakan kriminal

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

5) Adakah anggota keluarga yang mengalami gangguan jiwa?

 Ya
 Tidak
Hubungan dengan keluarga :...............................................................................
................................................................................
Gejala :...............................................................................
................................................................................
Riwayat pengobatan :...............................................................................
6) Adakah pengalaman masa lalu yang menyakitkan?
Jelaskan :........................................................................................
.........................................................................................
.........................................................................................
..

Masalah Keperawatan :........................................................................................

 .........................................................................................

4. Faktor Presipitasi
Jelaskan :........................................................................................
.........................................................................................
.........................................................................................
..

Masalah Keperawatan :........................................................................................

.........................................................................................

5. Pemeriksaan Fisik
1) Tanda Vital
TD : ................mmHg
Nadi : ................x/mnt
Suhu : ................oC
Respirasi : ................x/mnt
2) Ukuran
Berat Badan : ................Kg
TB : ................cm
3) Keluhan fisik
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

6. Psikososial
1) Genogram
: perempuan
: laki-laki
: meninggal
: orang tinggal
serumah
: orang terdekat
dengan pasien
: klien
: cerai atau putus
hubungan

Jelaskan :.............................................................................................................
 ..............................................................................................................
..

2) Konsep Diri
a) Citra Diri
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

b) Identitas Diri
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

c) Peran diri
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

d) Ideal diri
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

e) Harga Diri
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

Masalah Keperawatan :........................................................................................

.........................................................................................

3) Hubungan Sosial
a) Orang yang berarti
Jelaskan :...........................................................................................................
............................................................................................................

b) Peran serta dalam kehidupan masyarakat/kelompok

Jelaskan
:...................................................................................................................................................
....................................................................................................................................................
............................

c) Hambatan dalam berhubungan dengan orang lain

d)
Jelaskan

:...................................................................................................................................................
....................................................................................................................................................
............................

Masalah Keperawatan

:...................................................................................................................................................
..............................
4) Spiritual
a) Nilai dan keyakinan
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

b) Kegiatan ibadah
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

Masalah Keperawatan :........................................................................................

.........................................................................................

7. Status Mental
1) Penampilan
 Tidak rapi
 Penggunaan pakaian yang tidak sesuai
 Cara berpakaian tidak seperti biasanya
Jelaskan :...........................................................................................................
............................................................................................................
............................................................................................................

Masalah Keperawatan :........................................................................

.........................................................................

2) Pembicaraan
  Cepat  Keras  Gagap  Inkoheren
 Apatis  Lambat  Membis  Tidak mampu memulai
 Kecil u pembicaraan

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
....

Masalah Keperawatan :......................................................................................

.......................................................................................

3) Aktivitas motorik
Penurunan

 Hipokinesia  Sub Stupor  Katalepsia  Flesibilitas

Katatonik serea

Peningkatan

 Hiperkinesi  Gaduh gelisah  Tremor  Konfulsif

a katatonik
 Grimase
 TIK

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

4) Alam perasaan
 Sedih  Khawatir  Ketakutan
 Putus asa  Gembira berlebihan

Jelaskan :.............................................................................................................
 ..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

5) Afek dan emosi

 Adekuat  Inadekuat  Datar/dangka  Tumpul
 Labil  Anhedonia l  Euforia
 Ambivalensi  Apatis  Kesepian  Cemas
 Marah

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
....

Masalah Keperawatan :......................................................................................

.......................................................................................

6) Interkasi selama wawancara

 Bermusuhan  Kontak mata berkurang  Gagap
 Tidak kooperatif  Defensif  Membisu

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
....

Masalah Keperawatan :......................................................................................

.......................................................................................

7) Persepsi
 Pengecapan  Perabaan  Penghidu
  Pendengaran  Penglihatan

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

8) Arus pikir
 Koheren  Inkoheren  Sirkumtansial
 Tangensial  Asosiasi longgar  Flight of idea
 Blocking  Perseverasi  Logorea

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

9) Isi pikir
 Obsesi  Dipersonalisasi  Pikiran magis
 Fobia  Ide yang terkait  Hipokondria
Waham

 Agama  Nihilistik  Curiga  Kontrol

 Somatik  Sisip pikir  Kebesaran pikir
 Siar pikir

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................
 10) Bentuk Pikir
 Realistik  Non Realistik

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
....

Masalah Keperawatan :......................................................................................

.......................................................................................

11) Tingkat kesadaran

 Bingung  Stupor  Disorientasi orang
 Sedasi  Disorientasi waktu  Disorientasi tempat

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

12) Memori
 Gangguan daya ingat jangka panjang  Gangguan daya ingat
saat ini
 Gangguan daya ingat jangka pendek  Konfabulasi

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

13) Tingkat konsentrasi dan berhitung

  Mudah beralih  Tidak mampu berkonsentrasi
 Tidak mampu berhitung sederhana

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

14) Kemampuan penilaian

 Gangguan ringan  Gangguan bermakna

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
..

Masalah Keperawatan :......................................................................................

.......................................................................................

15) Daya tilik diri

 Mengingkari penyakit yang diderita
 Menyalahkan hal-hal diluar dirinya

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

8. Kebutuhan Perencanaan Pulang

1) Makan dan minum
 Bantuan Minimal  Bantuan Total  Mandiri

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

2) BAB dan BAK

 Bantuan Minimal  Bantuan Total  Mandiri

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

3) Mandi
 Bantuan Minimal  Bantuan Total  Mandiri

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

4) Istirhat tidur
Jelaskan :..................................................................................................................
...................................................................................................................

5) Penggunaan obat
  Bantuan Minimal  Bantuan Total  Mandiri

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

Masalah Keperawatan :......................................................................................

.......................................................................................

6) Pemeliharaan kesehatan
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

7) Aktifitas dirumah
Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

8) Aktifitas diluar rumah

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
...

9. Mekanisme Koping
Adaptif Maladaptif

 Bicara dengan orang lain  Minum alkohol

 Mampu menyelesaikan masalah  Reaksi lambat/berlebihan
 Teknik relokasi  Bekerja berlebihan
 Aktivitas konstruktif  Menghindar
 Olahraga  Mencederai diri
 Lainnya ........................................  Lainnya..................................

Jelaskan :.............................................................................................................
..............................................................................................................
..............................................................................................................
 ...

Masalah Keperawatan :......................................................................................

.......................................................................................

10. Masalah Psikososial Dan Lingkungan

Masalah dengan dukungan kelompok

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah berhubungan dengan lingkungan

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah dengan pendidikan

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah dengan perumahan

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah dengan ekonomi

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah dengan pelayanan kesehatan

Jelaskan :................................................................................................................
.................................................................................................................
 .................................................................................................................

Masalah lainnya

Jelaskan :................................................................................................................
.................................................................................................................
.................................................................................................................

Masalah Keperawatan :........................................................................................

.........................................................................................

11. Pengetahuan
 Penyakit jiwa  Sistem pendukung
 Faktor presipitasi  Penyakit fisik
 Koping  Obat-obatan
 Lainnya ........................................

Masalah Keperawatan :........................................................................................

.........................................................................................

12. Aspek Medik

1) Diagnosa Medik :.............................................................................................
.............................................................................................

2) Terapi Medik :.............................................................................................

.............................................................................................

13. Analisadata
No Data subyektif Data Objektif Kesimpulan

1 2 3 4
 14. Rumusan masalah
1. ....................................................................................................................................
..............................................................................................................................
2. ....................................................................................................................................
..............................................................................................................................
3. ....................................................................................................................................
..............................................................................................................................

15. PohonMasalah

Bangli,..............................................20......

Mahasiswa,

..................................................................
.

NIM.
II. Diagnosa Keperawatan
1.
................................................................................................................................................
................................................................................................................................
2. ...........................................................................................................................................
.....................................................................................................................................
3. ...........................................................................................................................................
.....................................................................................................................................
4. ...........................................................................................................................................
.....................................................................................................................................
5. ...........................................................................................................................................
.....................................................................................................................................
 III. Perencanaan
1. Diagnosa Prioritas (Core Problem)
...........................................................................................................................................
...........................................................................................................................................
......................................................................................................

RENCANA TINDAKAN KEPERAWATAN

Inisial Klien :........................................

Ruangan :........................................
No.RM :........................................

Hari, Rencana Tindakan Keperawatan

Diagnosa
tgl, Paraf
Keperawatan NOC NIC Rasional
jam
 IMPLEMENTASI ASUHAN KEPERAWATAN

Inisial Klien :................................................

Ruangan : ...............................................
No. R.M :................................................

Hari, Diagnosa Implementasi Respon (Evaluasi

Paraf
tgl, jam Keperawatan Keperawatan Formatif)
 EVALUASI SUMATIF/
CATATAN PERKEMBANGAN

Inisial Klien : ............................................

Ruangan :.............................................
No. R.M :.............................................
Hari, tgl, Evaluasi Sumatif
Diagnosa keperawatan Paraf
jam (SOAP)
 STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama : ............................................................
Pertemuan : ............................................................
Topik : ............................................................

1. Proses Keperawatan
1) Kondisi Klien
Ds :.............................................................................................................................. ...
 ............................................................................................................................ ......
......................................................................................................................... .........
......................................................................................................................

Do :.............................................................................................................................. ...
............................................................................................................................ ......
......................................................................................................................... .........
......................................................................................................................

2) Diagnosa Keperawatan
..........................................................................................................................................
..........................................................................................................................................

3) Tujuan Khusus
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...............

Tindakan Keperawatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............
2. Strategi Komunikasi dalam Proses Pelaksanaan Keperawatan
1. Fase Orientasi
1) Salam Terapeutik
.....................................................................................................................................
.....................................................................................................................................
................................................................................................. ..................................

2) Evaluasi dan validasi

.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

3) Kontrak
Topik
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Waktu
 .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Tempat
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

2. Kerja
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
...............
3. Fase Terminasi
1) Evaluasi
a) Subyektif
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
............

b) Obyektif
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
............

2) Rencana Tindak Lanjut

.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
...............

3) Kontrak Yang Akan Datang

a) Topik
.................................................................................................................................
.................................................................................................................................
........

b) Waktu
.................................................................................................................................
.................................................................................................................................
........

c) Tempat
.................................................................................................................................
.................................................................................................................................
........
 .........................., ...................................2019
Mahasiswa,

......................................................................
NIM.
Mengesahkan,
Clinical Instruktur (CI) Clinical Teacher (CT)
Ruang ....................... .....................................................................
RSJ Provinsi Bali – Bangli, STIKES Buleleng,

..................................................................... ......................................................................
NIP. NIK.

DAFTAR KEGIATAN HARIAN MAHASISWA

Nama :
NIM :
Ruangan :
No Hari/tgl/jam Rencana Kegiatan Hasil Kegiatan TTD CI TTD CT
Kegiatan Tambahan