ASUHAN KEPERAWATAN

Tanggal Pengkajian :
Nama Pengkaji :.........................................................................................................
Ruang :.........................................................................................................
Waktu Pengkajian :.........................................................................................................
A.    IDENTITAS KLIEN
Nama  :........................................................................................................
Umur    :.........................................................................................................
JenisKelamin :.........................................................................................................
Alamat    :.........................................................................................................
Status                              :.........................................................................................................
Agama   :.........................................................................................................
Suku     :.........................................................................................................
Pendidikan   :.........................................................................................................
Pekerjaan     : ........................................................................................................
Tanggalmasuk RS  :.........................................................................................................
No. RM              :.........................................................................................................
DiagnosaMedik     :.........................................................................................................

B.     IDENTITAS PENANGGUNG JAWAB

Nama     :.........................................................................................................
Umur     :.........................................................................................................
Jenis Kelamin  :.........................................................................................................
Alamat      :.........................................................................................................
Pendidikan  :.........................................................................................................
Pekerjaan   :.........................................................................................................
Hubungan dengan klien :.........................................................................................................

C.    KELIHAN UTAMA        
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D.    RIWAYAT KESEHATAN SEKARANG        
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E.     RIWAYAT KESEHATAN DAHULU 
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F.     RIWAYAT KESEHATAN KELUARGA       
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G.    GENOGRAM      
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H.    RIWAYAT GINEKOLOGI       :
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I.       RIWAYAT KEHAMILAN DAN PERSALINAN YANG LALU    

No Tahun Jenis Penolong J. Keadaan Bayi Masalah

Persalinan K Waktu Lahir Kehamilan
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Pengalaman menyusui :                                           Berapa lama :

J.      RIWAYAT KB                                        
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K.    RIWAYAT KEHAMILAN SAAT INI 

HPHT :.........................................................................................................
Taksiran Partus   :.........................................................................................................
BB Sebelum Hamil :.........................................................................................................
TB Sebelum Hamil       :.........................................................................................................

TD BB TFU LETAK DJJ Usia Keluhan Data

Gestasi lain
-

L.  RIWAYAT PSIKOSOSIAL
Keadaan mental    :.........................................................................................................
Adaptasi psikologis   :.........................................................................................................
Penerimaan terhadap kehamilan  :............................................................................................
Masalah khusus   :.........................................................................................................
M.   POLA HIDUP YANG MENINGKATKAN RESIKO KEHAMILAN   
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N.    PERSIAPAN PERSALINAN  
Senam hamil: ...........................................................................................................................
Rencana tempat melahirkan:....................................................................................................
Perlengkapan kebutuhan bayi dan ibu: ....................................................................................
Kesiapan mental ibu dan keluarga: .........................................................................................
Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses
persalinan:
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Perawatan payudara: ................................................................................................................

O.    OBAT-OBAT YANG DIKONSUMSI SAAT INI

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P.   POLA FUNGSIONAL MENURUT GORDON

1.    Pola Persepsi-Managemen Kesehatan
Saat dikaji : ........................................................................................................
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2.    PolaNutrisi-Metabolik
Saat dikaji :.........................................................................................................
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3.    PolaEliminasi
Saat dikaji :.........................................................................................................
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4.    PolaLatihan-Aktivitas
Saat dikaji               :.........................................................................................................
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5.    PolaKognitif Perseptual
Saat dikaji               :..................................................................................................
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6.    PolaIstirahat-Tidur
Saat dikaji               :.........................................................................................................
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7.    PolaKonsep Diri-Persepsi Diri
Saat dikaji :.........................................................................................................
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8.    Pola Peran Dan Hubungan
Saat dikaji               :.........................................................................................................
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9.    Pola Reproduksi-Seksual
Saat dikaji   :.........................................................................................................
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10.    Pola Pertahanan Diri (Coping-Toleransi Stres )
Saat dikaji    :.........................................................................................................
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11.    Pola Keyakinan Dan Nilai
Saat dikaji               :.........................................................................................................
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Q.    PEMERIKSAAN FISIK
Status obstetric       : G :               P :                  A:                 
Keadaan umum      :                                   Kesadaran : 
BB/TB                    :   kg/ cm
Tanda- Tanda Vital            ;          
Tekanan darah        : …….. mmHg                      Nadi    : …. x/menit
Suhu                       : …..oC                                   Pernafasan : …. x/menit

Kepala- leher
Kepala               :
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Mata                  :.........................................................................................................
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Hidung             : ........................................................................................................
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Mulut                 : ........................................................................................................
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Telinga               :.........................................................................................................
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Leher                  :.........................................................................................................
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Masalah khusus :

Dada
Paru-paru (SistemPernapasan) :
Inspeksi :.........................................................................................................................
Palpasi :.........................................................................................................................
Perkusi :.........................................................................................................................
Auskultasi :.........................................................................................................................
Jantung (Sistem Kardiovaskuler) :
Inspeksi :.........................................................................................................................
Palpasi :.........................................................................................................................
Perkusi :.........................................................................................................................
Auskultasi :.........................................................................................................................

Payudara : 

Puting susu :
Pengeluaran ASI         : -
Masalah khusus           : Tidak ada

Abdomen
Inspeksi :
Auskultasi :
Palpasi :
Perkusi :
Ekstremitas   
Ekstremitas Atas  :
EkstremitasBawah :
Masalah khusus      : -
R.    PEMERIKSAAN PENUNJANG  :
1. Laboratorium
2. Pemeriksaan Antigen SarsCovid (-)
1. Pemeriksaan Palpasi Abdomen
a. Leopold I : TFU 3 jari di atas pusat dan 3 jari di bawah PX. Pada fundus
teraba bulat, besar, lunak, tidak melenting kesimpulan pada bagian fundus
teraba bokong janin
 b. Leopold II : Pada perut sebelah kanan ibu teraba rata/datar, panjang, lebar
kesimpulan punggung janin. Pada perut sebelah kiri ibu teraba bagian-
bagian kecil janin kesimpulan ekstremitas janin
c. Leopold III : Pada bagian perut bawah ibu teraba bulat, keras, melenting
kesimpulan kepala janin tidak dapat digoyangkan kesimpulan kepala
janin sudah masuk panggul
d. Leopold IV : Posisi tangan memeriksa divergen kesimpulan kepala janin
sudah masuk panggul
2. Hasil Pemeriksaan Dalam : Saat di VT terdapat pembukaan 8,ketuban
masih utuh, portio lunak, kepala d hodge II,
3. Persiapan Perineum : tidak ada persiapan
4. Dilakukan klisma : tidak dilakukan
5. Pengeluaran pervaginaan : terdapat lendir darah
6. Perdarahan pervaginaan : tidak ada perdarahan
7. Kontraksi uterus : 1x dalam 5 menit, durasi 10 detik, lemah
8. Denyut jantung janin : 144 x/menit, regulerStatus janin : hidup, tunggal,
presentasi kepala

S.      PROGRAM TERAPI     
KALA PERSALINAN
1. KALA I
a. Ketuban pecah sejak jam
b. Mulai persalinan :
c. Tanda dan Gejala :
d. TTV:
e. Lama kala I jam: menit: detik : 0
f. Keadaan psikososial :
g. Masalah keperawatan
h. Obeservasi kemajuan persalinan

Tgl/Jam Kontraksi Uterus DJJ Nadi TD Keterangan

KALA II
a. Kala II dimulai:
b. Tanda-tanda vital :
c. Lama kala I : 11jam :
d. Tanda dan gejala :
e. Jelaskan upaya meneran :
f. Pendamping saat melahirkan :
g. Keadaan psikososial :
h. Masalah Keperawatan :
i. Tindakan :
CATATAN KELAHIRAN
a. Bayi lahir jam :
b. Nilai APGAR menit I :
c. Perineum :
d. Bonding ibu dan bayi :
e. Tanda-tanda vital : TD:
f. Pengobatan bayi:
.KALA III
a. Lama Kala III
b. Tanda dan gejala :
c. Plasenta lahir jam :
d. Cara lahir plasenta :
e. Karakteristik plasenta :
Ukuran :
Panjang tali pusat :
Kelainan :
f. Jumlah Perdarahan :
g. Peregangan tali pusat terkendali
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h. Messase fundus uteri :
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i. Plasenta lahir < 30 menit
j. Keadaan psikososial :
k. Masalah Keperawatan :
l. Tindakan :
B. KALA IV
Pemantauan persalinan kala IV
Jam Waktu TD N S TFU Kontraksi Kandung Perdaraha
Ke uterus kemih n
1

Bonding ibu dan bayi:ya, IMD segerasetelahbayilahir

Tindakan = pemantauankala IV
Bayi
a. bayi lahir tanggal/jam:
b. jenis kelamin:
c. nilai APGAR :
d. BB/PB/Lingkar kepala bayi:
LD/LL/LP:
e. Karakteristik khusus bayi :
f. Kaput : suksedaneum/ceephalhematom:
g. Suhu :
h. Nadi :
i. RR :
j. Anus :
k. Perawatan tali pusat:
l. Perawatan mata :
m. Pemberian ASI < 1 Jam
 V. INTERVENSI KEPERAWATAN
Hari/Tgl No SLKI SIKI TTD&
Dx Paraf
 W. IMPLEMENTASI KEPERAWATAN
Hari/Tgl No Tindakan Respon TTD&
Dx Paraf
 X. EVALUASI
Hari/Tgl No. Evaluasi TTD&
Dx Paraf