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

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

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

B. ALASAN DIRAWAT
1. Alasan MRS
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2. Keluhan saat dikaji
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C. RIWAYAT OBSTERTRI DAN GINOKOLOGI
a. Riwayat Menstruasi :
 Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : .................... Lamanya : .....................................
 Keluhan : ....................
 HPHT : ....................

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

c. Riwayat kehamilan, persalinan, nifas yang lalu :
Anak ke K e h a m i l a n P e r s a l i n a n K o m p l i k a s i n i fa s A n a k
No Tahun Umur kehamilan Penyulit Jenis Penolong Penyulit Laserasi Infeksi Pedarahan Jenis kelamin BB Pj

d. Riwayat Keluarga Berencana :
 Akseptor KB : jenis ............... Lama : ..................
 Masalah : .......................
 Rencana KB : .......................

E. POLA FUNGSIONAL KESEHATAN
1. Pemeliharaan dan persepsi terhadap kesehatan
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2. Nutrisi/ metabolik
Sebelum sakit : ....................................................................................................................
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Saat sakit : ....................................................................................................................
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3. Pola eliminasi
BAB
Sebelum sakit : ....................................................................................................................
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Saat sakit : ....................................................................................................................
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BAK
Sebelum sakit : ....................................................................................................................
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Saat sakit : ....................................................................................................................
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4. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
M a k a n / m i n u m
M a n d i
T o i l e t i n g
B e r p a k a i a n
Mobilisasi ditempat tidur
B e r p i n d a h
A m b u l a s i R O M
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat,
4: tergantung total.
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5. Oksigenasi
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6. PolaTidur dan istirahat
Sebelum sakit : ....................................................................................................................
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Saat sakit : ....................................................................................................................
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7. Pola perseptual
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........................................................................................................................................................... Pola seksual dan reproduksi …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………............................................. Pola peran-hubungan Sebelum sakit : .............................................................................................. LILA =…............................................ ............ Saat sakit : ..................Beratbadan : ........................... ...................................................GCS : ........... ....................................................................................................................................... PEMERIKSAAN FISIK Keadaan umum .... Pola manajemen koping stress ................... Pola persepsi diri ................... ........................ S= .................................................................................................................... RR =............................. ............................................................................................................... ............................................................................ TB =................................................................................................................................................................................................................................................................................................................................................ ........................ .................................................................. 12.................... Sistem nilai dan keyakinan Sebelum sakit : .............................. 10..................... ................................. ....... .................................................................................................................. .............Tingkat kesadaran : ........ .................................................................................................................................................................................. …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………................................................................ 9.................................................................................................................................................................. 11................................................. Saat sakit : .................................................................................... Head to toe ...............................Tanda-tanda vital : TD =..... ............................................................................................................................................................................ …………………………………………………………………………………………………… …………………………………………………………………………………………………..................................... .............................................................................................................................................................................................................................................................................................. ...................................................... 8..................................................................................................... ..................................................................................................................... .. .................. . N =........................................................ E........................................................................ ......................................................................................................... ........................................ KepalaWajah ................................. ...

............................................. ……………………………………………………………… ……………………………………………………………… ………………………………………………………………........................... ..... ...................... ……………………………………………………………… ……………………………………………………………… ………………………………………………………………......................................................................................................................................................  Palpasi : ........................................................ ……………………………………………………………… ……………………………………………………………… ……………………………………………………………….................. ……………………………………………………………… ……………………………………………………………… ……………………………………………………………….  Palpasi : ............. .............. Leher  Inspeksi : ........................................................  Palpasi : ....  Palpasi : .................................................... ..................................................... ……………………………………………………………… ……………………………………………………………… ………………………………………………………………..................................................................................... Dada Jantung  Inspeksi : .......................................... ……………………………………………………………… ……………………………………………………………… ………………………………………………………………..........................  Inspeksi : .. ……………………………………………………………… ……………………………………………………………… ………………………………………………………………................................................................ Mata  Inspeksi : ............................................................

....... ......................................  Perkusi : ........................................................... Paru-paru  Inspeksi : ................  Bising usus : ………………………………………………… ……………………………………………….. ................ ……………………………………………………………… ……………………………………………………………… ……………………………………………………………….....  Perkusi : .........................................................................................................................................................  Kontraksi : ………………………………………………… ………………………………………………................................. ……………………………………………………………… ……………………………………………………………… ………………………………………………………………..................................................  Satriae : ………………………………………………… ……………………………………………….........................................................  Palpasi : ...... ……………………………………………………………… ……………………………………………………………… ……………………………………………………………….................. Abdomen  Linea : ………………………………………………… ………………………………………………................  Diastase rectus abdominis : ………………………………………………… ………………………………………………... ……………………………………………………………… ………………………………………………………………  Auskultasi : ..................................................... Genetalia  Kebersihan : ………………………………………………… ...........  TFU : ………………………………………………… ………………………………………………....... ……………………………………………………………… ………………………………………………………………  Auskultasi : ..............................................................

.................  Hemoroid : .......... ........................... ................................................. CRT : .............................................................................. ................................ Varises : .................. ...................................................................................................................................................................................................................................................................................................................................... CRT : ....... ....................................... DATA PENUNJANG .......................................................................................................................... Ekstremitas  Atas Oedema : ............................................................. ........................ .............................................................................................................................................................................................................................................................................................................................................................................................................................................. .. .................................................................................................................. .............................  Lochea : ………………………………………………… ………………………………………………............................... ............................................................... Perineum dan anus  Perineum : ...................................... Varises : ............................................... F.......................................................................................................................................................... .................................................. ....................................... ................. .......................................................................................................................................... ..................................................................................................................................................................................................................... Pemeriksaan Reflek : ............. ....... ......................................................................................................................................................... ...................................................................................................................................................................................... ........................................................................................................................................... ....................................................................................................................................................................................................................................................................... Turgorkulit : ........................................................ ……………………………………………… ………………………………………………............................................................................................. ................................................................................................................................  Bawah Oedema : ................................................................................................ .............................................................................. ............................................................................................................. ..................................................................................................................................................................... ....................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................................... ………………………………………………......

............................................................................................................................................................................................................................................................................................................................................................................. ...................................................... .................................................................................................................. ................................................................................................................................ .......................................... ............... ..................................................................................................................................................................... ........................................................................................................................................................................................... ....................................................................................................................................................................................................................... H............................................................................................................................................................................................................................................................................ ............................................................................ .................................. ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ............. .......................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................ ............................................ . ....................................................... .............................. ........................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ...................................................................... .................................. ............................................................................................... ................................................................................................................ ..................................................................................................................................................................... .................................................................................................................... PENGOBATAN ............................................................. ........................................................................ ..................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................ ....... G.................................................................................................... .......................................................................................................................................... ................................................................................................................................................................................................................................................................................... .............................................................................................................................. ............................................................................ .............................................................................. ................................................................................................................................................................................ .................................................................................................................................................................................................................. ............................................................................................................................................................................................... DIAGNOSA MEDIS ...................... ............ ...................................................................... ............................................................................................................................................. ......... ........................................................ .............................................................................................

...... ....... ..... ………………………............... ………………….. ………………….......... ………………….. ………………….............. …………………........... …………………………………………….. ……………………………………………... ANALISA DATA NO D A T A E T I O L O G I MASALAH …………………………………………….. .... ……………………….. ……………………………………………......... ................ ………………………. ………………………. ………………….. ………………………..... .... ...... …………………......................... .. ……………………….... …………………... ………………………........ …………………..... …………………...... ………………………... …………………...... ……………………………………………. II........ ……………………………………………… ………………………............ …………………..... ……………………………………………… ………………………........... .............................. . ............................ ……………………………………………… ………………………... …………………................................. …………………. ………………………..... ...................... ………………………... ………………….......... ………………………. ……………………………………………… ………………………....... ………………………............... …………………........ ………………………... …………………............

.. ………………….... …………………………………………….... ……………………….. ……………………….. ………………………. …………………. . . ………………….. …………………. …………………………………………….... …………………. ………………………..... ……………………….. ……………………….. ……………………………………………… .. ……………………………………………… ………………………. .. ………………….. ……………………………………………. ……………………………………………… ………………………. . ……………………………………………… ……………………….. ………………….. ……………………….. . …………………. ………………………. ………………….. ……………………….. …………………. ……………………………………………… . .. …………………………………………….. ……………………………………………… . . . …………………. …………………. …………………. ………………….. ………………….. ……………………………………………… . ……………………………………………… ………………………. ……………………………………………. ... ………………………. …………………...... ……………………………………………... ……………………….. …………………. ……………………………………………… . ………………….. …………………. ……………………………………………. ……………………………………………… ………………………. ...... ……………………………………………....... ………………….. …………………. ………………………... ………………………. .. ………………………. ………………….......... ……………………………………………… ... ……………………………………………. …………………. .. ………………………. ……………………………………………. ………………………..... …………………. . ……………………………………………. ……………………………………………… ………………………... .. …………………. ……………………………………………. ………………….. ………………………...... ………………………. .. . ……………………………………………… ……………………….. …………………. .. …………………... ………………………. ……………………….. ……………………….. ... . …………………... ………………………..

.. . ……………………………………………… ... ………………………. ……………………………………………… .. .... …………………. ANALISA DATA NO D A T A E T I O L O G I MASALAH ……………………………………………... ... ………………….... ... …………………. . ……………………….. ……………………….. …………………... ……………………………………………. ………………….. ………………………. …………………. ………………………. …………………. …………………. ………………………. …………………………………………….... ……………………………………………… ………………………. …………………....... ………………………... .. ..... . .. …………………. ………………………. .. ……………………………………………… ………………………. ……………………………………………… . ……………………………………………… ………………………. …………………..... ……………………………………………… . ……………………….. …………………. ..... . .. ... …………………. ………………….. ………………….. ……………………………………………. ……………………………………………. ……………………………………………... …………………. . ……………………………………………. ……………………………………………. ……………………………………………… . . …………………. ……………………….... …………………. ……………………….. ………………………. ……………………………………………… .. …………………………………………….. …………………………………………….... .. ……………………….. ………………….. …………………………………………….. ……………………………………………… ……………………….. …………………... …………………………………………….. ………………………... ……………………….. ……………………….. . …………………. ……………………………………………… ………………………..

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. …………………. ……………………………………………… . ………………………... ……………………………………………… .. ANALISA DATA NO D A T A E T I O L O G I MASALAH ……………………………………………. . ……………………………………………… ……………………….. ………………….. ……………………………………………… ………………………... . ……………………………………………. ………………………. ………………….... …………………. . ………………………. .... ……………………………………………..... ………………….. . ………………………. ………………….. ……………………………………………… ………………………. ………………………. ……………………….. ……………………………………………… ………………………..... ………………………. ………………….... ………………………. ……………………….. ……………………………………………... …………………. .. . .. ……………………………………………… ……………………….. ………………….. ……………………………………………. ………………………. …………………. ……………………….. . ... ……………………………………………. . . ……………………….. ……………………………………………...... ………………….. ……………………………………………. ………………………. …………………........ .. …………………. …………………. …………………………………………….... ……………………….. . …………………. . …………………. ……………………………………………… . ………………….... …………………. .... ……………………………………………… ………………………... ……………………………………………. ………………….. ……………………………………………. ……………………….. . ………………….. ……………………………………………… ...... ……………………….... ………………….. . . …………………... ………………………. …………………...... ………………….. ………………………. ………………………. ……………………………………………. ……………………………………………… . …………………..

... . ……………………………………………… ………………………. . ……………………………………………… ……………………….. …………………. ………………….. …………………. . ……………………………………………. ………………………. ……………………………………………. ………………………. ……………………….. ……………………………………………… . . ……………………………………………. . ………………………. . ……………………………………………… . …………………. . ……………………………………………… ………………………..... ........ …………………..... ………………….... ……………………….. ………………………. ……………………….. ……………………………………………… ... ... ………………….. ……………………………………………… ... ………………………. …………………. ……………………………………………… . ……………………………………………... …………………. …………………. ……………………….. ………………………. ………………….. …………………………………………….... ……………………………………………… ………………………. …………………. ……………………………………………. ……………………………………………… . ……………………………………………… . ……………………………………………… ..... ………………….... …………………... ... …………………………………………….. ……………………………………………. ... ………………….... ... ………………………... ………………………. ……………………………………………… ………………………. . ………………….. …………………...... ……………………………………………. ………………….. …………………………………………….. …………………. ………………………. ……………………….. …………………………………………….. . .. ……………………….. …………………………………………….. . …………………... ………………………. .. …………………...

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. …………………………………………….. . . III. ……………………………………………. . ……………………………………………… . DIAGNOSA KEPERAWATAN NO..... ……………………………………………… .. TGL/JAM DITEMUKAN D I A G N O S A K E P E R AWATA N TGL TERATASI TTD ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… .. ……………………………………………. ……………………………………………… . ..

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TGL/JAM DITEMUKAN D I A G N O S A K E P E R AWATA N TGL TERATASI TTD ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… . ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… DIAGNOSA KEPERAWATAN NO.

…………………………. …………………………. …………………………. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. ………………………….. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. …………………………. RENCANA KEPERAWATAN N O NO DX R E N C A N A P E R A W A T A N TTD TUJUAN DAN KH I N T E R V E N S I R A S I O N A L ………………………….. ………………………….. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………... …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. ………………………….. ………………………….. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. …………………………... ………………………….. …………………………. …………………………. …………………………. …………………………. …………………………. ………………………….. ………………………….. …………………………... ………………………….. …………………………. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. …………………………. ………………………….. …………………………. …………………………. ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… IV. …………………………. ………………………….. …………………………. ………………………….. …………………………. ………………………….. ………………………….. .. …………………………... …………………………. …………………………. …………………………. ………………………….. …………………………. ………………………….. …………………………. …………………………. …………………………. …………………………. …………………………. ………………………….. …………………………. ………………………….. ………………………….. …………………………. …………………………. ………………………….. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. …………………………. ………………………….

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