ASUHAN KEPERAWATAN

PADA KLIEN……......... DENGAN………..………….……….

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

PERIODE TANGGAL …………..……….. - ……………… 2018

Oleh :

NAMA : _____________________________
NIM : _____________________________

PRODI D3 KEPERAWATAN KAMPUS LUMAJANG

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
 LEMBAR PENGESAHAN

LAPORAN INI TELAH DISAHKAN PADA

TANGGAL ................................. 2018

PEMBIMBING KLINIK MAHASISWA

....................................................... ..................................................
NIP. .............................................. NIM. .....................

PEMBIMBING AKADEMI

.......................................................
NIP. ..............................................
 FORMAT PENGKAJIAN ANTE NATAL
UNIT KEPERAWATAN MATERNITAS
NAMA MAHASISWA : .......................................................................................................................................

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

TINGKAT/SEMESTER : ......................................................................................................................................

TANGGAL PRAKTIK : .......................................................................................................................................

TEMPAT PRAKTIK : .......................................................................................................................................

Ruang / Kelas :
Tanggal MRS ......................................................................................................................................
Tanggal : ..................................................................Jam : ..........................................................
Pengkajian : ..................................................................Jam : ................................................... .......
Diagnosa Medis :
......................................................................................................................................

A. IDENTITAS
Inisial Klien : ............................................. Nama Suami : ................................................
Usia : ............................................. Usia : ................................................
Suku/Bangsa : ............................................. Suku/Bangsa : ................................................
Agama : ............................................. Agama : ................................................
Pendidikan : ............................................. Pendidikan : ................................................
Pekerjaan : ............................................. Pekerjaan : ...............................................
Alamat : ............................................. Alamat : ................................................
Status Perkawinan : .............................................

C. KELUHAN UTAMA
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
........................................................................................................................................ ...............................
.......................................................................................................................................................................
........................

D. RIWAYAT KEHAMILAN SEKARANG

a. HPHT / HPL : ............................................................................................................
b. Keluhan
Trimester I : ............................................................................................................
Trimester II : ............................................................................................................
Trimester III : ............................................................................................................

c. Pergerakan janin pertama kali : ...............................minggu

d. Pergerakan janin 24 jam < 10 kali 10 – 20 kali > 20 kali
terakhir

E. RIWAYAT KEPERAWATAN
a. Riwayat penyakit yang sedang/pernah diderita
 Jantung : ..................................................................................................
 Ginjal : ..................................................................................................
 Asma/TB paru : ..................................................................................................
 Hepatitis : ..................................................................................................
 Epilepsi : ..................................................................................................
 Lain-lain : ..................................................................................................

b. Riwayat penyakit keluarga

  Jantung : ..................................................................................................
 Gangguan jiwa : ..................................................................................................
 Hipertensi : ..................................................................................................
 DM : ..................................................................................................

c. Riwayat menstruasi
Menarche umur :…………………………………… Siklus : teratur / tidak teratur
Banyaknya : ………………………………cc Lamanya : …………….hari
Keluhan :
……………………………………
Cara mengatasi :
……………………………………

d. Riwayat Kehamilan, persalinan, nifas yang lalu : G______P_____________

ANAK KEHAMILAN PERSALINAN KOMPLIKASI NIFAS ANAK

KE

N TH UMUR PENYU JENI PENOL PENY LASER INFE PERDAR JENI BB PB

O N KEHAMIL LIT S ONG ULIT ASI KSI AHAN S
AN

F. GENOGRAM

G. KEBUTUHAN DASAR
1. Nutrisi
 Frekuensi makan : .............................x/hari
 Jenis makanan : .....................................................................................
 Perubahan yang dialami : .....................................................................................
 Cara mengatasi : .....................................................................................

 Frekuensi minum : ..........................gelas/hari

 Minuman tambahan : .....................................................................................

2. Eliminasi
BAK
 Frekuensi : .............................x/hari
 Warna : ........................................................................................
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................
BAB
 Frekuensi : .............................x/hari
 Warna : ........................................................................................
 Konsistensi : ........................................................................................
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................

3. Personal Higiene
Mandi
 Frekuensi : .............................x/hari
  Sabun : ........................................................................................
Oral Hygiene
 Frekuensi : .............................x/hari
Ganti pakaian : ........................................................................................

4. Istirahat dan Tidur

Tidur Siang
 Frekuensi : .............................jam
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................
Tidur Malam
 Frekuensi : .............................jam
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................

5. Seksualitas
 Coitus/senggama : .............................x/minggu
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................

6. Aktifitas sehari-hari
 Pekerjaan : ........................................................................................
 Waktu bekerja : ........................................................................................
 Keluhan : ........................................................................................
 Cara mengatasi : ........................................................................................

H. RIWAYAT IMUNISASI
 TT 1 : kehamilan minggu ke ............................
 TT 2 : kehamilan minggu ke ............................

I. RIWAYAT KELUARGA BERENCANA

Melaksanakan KB : ……………………………………………………….
Bila ya, jenis kontrasepsi apa yang : ……………………………………………………….
digunakan
Sejak kapan menggunakan kontrasepsi : ……………………………………………………….
Keluhan : ……………………………………………………….
Cara mengatasi : ……………………………………………………….

J. PENYIMPANGAN PERILAKU HIDUP SEHAT

Merokok : Ya Tidak
Minuman keras : Ya Tidak
Obat – obatan terlarang : Ya Tidak

K. RIWAYAT PSIKOSOSIAL
Status emosional
Status kehamilan saat ini
Respon ibu/suami /keluarga terhadap
kehamilan
Ada/tidak kekhawatiran khusus
terhadap kehamilan
:
………………………………………………………………..
: Direncanakan dan diterima
Direncanakan dan tidak diterima
Tidak direncanakan dan diterima
Tidak direncanakan dan tidak diterima
: .........................................................................................
.........................................................................................
: .........................................................................................
.........................................................................................

L. PEMERIKSAAN FISIK
1. Pemeriksaan Umum
Keadaan umum
kesadaran
 Tanda – tanda vital  Tekanan Darah : ...........................mmHg
 Nadi : ...........................x / menit
 Pernafasan : ...........................x / menit
 Suhu : ............................ oC
BB sebelum hamil / BB sekarang : ....................kg / .......................kg
TB : ...................cm
LILA : ...................cm

2. Pemeriksaan Khusus
a. Wajah
 Cloasma : .........................................................................................
gravidarum : .........................................................................................
 Edema : .........................................................................................
 Kelainan

b. Mata
 Sklera : .........................................................................................
 Konjungtiva : .........................................................................................
 Kelopak mata : .........................................................................................
 Kelainan : .........................................................................................

c. Hidung
 Polip : .........................................................................................
 Sekret : .........................................................................................
 Sinusitis : .........................................................................................
 Kelainan : .........................................................................................

d. Mulut dan gigi

 Lidah : .........................................................................................
 Tonsil : .........................................................................................
 Stomatitis : .........................................................................................
 Epulsi : .........................................................................................
 Gigi : .........................................................................................

e. Telinga
 Letak : .........................................................................................
 Serumen : .........................................................................................
 OMA : .........................................................................................
 Kelainan : .........................................................................................

f. Leher
 Kelenjar tiroid : .........................................................................................
 Pembuluh limfe : .........................................................................................

g. Paru
 Inspeksi : .........................................................................................
 Palpasi : .........................................................................................
 Perkusi : .........................................................................................
 Auskultasi : .........................................................................................

h. Jantung
 Inspeksi : .........................................................................................
 Palpasi : .........................................................................................
 Perkusi : .........................................................................................
 Auskultasi : .........................................................................................

i. Payudara
 Letak : .........................................................................................
 Areola mamae : .........................................................................................
 Papilla mamae : .........................................................................................
 Colostrum : .........................................................................................
 Massa/benjolan : .........................................................................................
 Kelainan : .........................................................................................
 j. Aksila
 Pembengkakan : .........................................................................................
kelenjar (hypoma)

k. Abdomen
 Bekas luka/operasi : .........................................................................................
 Linea nigra : .........................................................................................
 Striae albicans : .........................................................................................
 Leopold I : .........................................................................................
 Leopold II : .........................................................................................
 Leopold III : .........................................................................................
 Leopold IV : .........................................................................................
 TBBJ : .........................................................................................
 DJJ : .........................................................................................
 Lainnya, sebutkan : .........................................................................................

l. Genetalia
 Varises : .........................................................................................
 Kemerahan : .........................................................................................
 Rabas : .........................................................................................
 Perineum : .........................................................................................
 Hemoroid : .........................................................................................
 Kelainan : .........................................................................................

m. Ekstremitas
 Turgor kulit : .........................................................................................
 Warna kulit : .........................................................................................
 Varises : .........................................................................................
 Edema : .........................................................................................
 Kontraktur pada : .........................................................................................
persendian
ekstremitas : .........................................................................................
 Kesulitan dalam : .........................................................................................
pergerakan : .........................................................................................
 Refleks patela
 Lainnya, sebutkan

M. PEMERIKSAAN LABORATORIUM
a. Hb : .........................................................................................
b. Protein urin : .........................................................................................
c. Glukosa : .........................................................................................

N. PEMERIKSAAN PENUNJANG LAIN

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………
 FORMAT PENGKAJIAN INTRA / POST NATAL
UNIT KEPERAWATAN MATERNITAS
NAMA MAHASISWA : ............................................................................................................................

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

TINGKAT/SEMESTER : .............................................................................................................. ..............

TANGGAL PRAKTIK : ............................................................................................................................

TEMPAT PRAKTIK : ............................................................................................................................

Ruang / Kelas : ........................................................................................................................... ...........

Tanggal MRS : ..................................................................Jam : ..........................................................
Tanggal : ..................................................................Jam : ................................................... .......
Pengkajian
Diagnosa Medis : ........................................................................................................................... ...........

B. IDENTITAS
Inisial Klien : ............................................. Inisial Suami : ................................................
Usia : ............................................. Usia : ................................................
Suku/Bangsa : ............................................. Suku/Bangsa : ................................................
Agama : ............................................. Agama : ................................................
Pendidikan : ............................................. Pendidikan : ................................................
Pekerjaan : ............................................. Pekerjaan : ................................................
Alamat : ............................................. Alamat : ................................................
Status Perkawinan : .............................................

C. KELUHAN UTAMA
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………

D. RIWAYAT PERSALINAN SEKARANG

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………

E. RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI
a. Riwayat Menstruasi
Menarche :…………………………………… Siklus : teratur / tidak teratur
umur
Banyaknya : ………………………………cc Lamanya : …………….hari
HPHT : Keluhan : ……………………...
……………………………………

b. Riwayat Kehamilan, persalinan, nifas yang lalu : G______P_____________

ANAK KE KEHAMILAN PERSALINAN KOMPLIKASI NIFAS ANAK

NO THN UMUR PENYULIT JENIS PENOLONG PENYULIT LASERASI INFEKSI PERDARAH JENIS BB PB
KEHAMILAN AN

c. Genogram
d. Persalinan sekarang
1 Keluhan His : ………………………………………………
Mulai kontraksi (tanggal/jam), : ………………………………………………
teratur/tidak : ………………………………………………
Interval : ………………………………………………
Lama : ………………………………………………
Kekuatan : ………………………………………………
2 Pengeluaran per vagina : lendir / darah / darah lender / air ketuban
Jenis : ………………………………………………
Jumlah : ………………………………………………
3 Periksa Dalam
Jam : ………………………………………………
Oleh : ………………………………………………
Hasil :
 Effacement : …………………………………………………%
 Ketuban : ………………………………………………
 Presentasi anak : ………………………………………………
 Bidang Hodge : ………………………………………………
4 Kala persalinan
a. Kala I : ………………………………………………
 Mulai : ………………………………………………
persalinan : ………………………………………………
(tanggal/ja : …………………Jam………………Menit
m)
 Lama Kala
I : ………………………………………………
 Pengobatan : …………………Jam………………Menit
yang : ………………………………………………
didapat
: ………………………………………………
b. Kala II : ………………………………………………
 Mulai (tanggal / jam) : ………………………………………………
 Lama Kala II : ………………………………………………
 Pengobatan yang didapat : ………………………………………………
: ………………………………………………
 Penyulit
 Cara mengatasi : ………………………………………………
 Keadaan bayi : ………………………………………………
 Lahir (tanggal / jam ) : baik / jelek
 Jenis kelamin : …………………Jam………………Menit
 Apgar Score 1 / Apgar Score 5 : ………………………………………………
c. Kala III : ………………………………………………
 Mulai (tanggal / jam) : ………………………………………………
 TFU : ………………………………………………
 Kontraksi uterus : ………………………………………………
 Lama Kala III
 Cara kelahiran plasenta : ………………………………………………
 Kotiledon
 Selaput : ………………………………………………
 Perdarahan selama persalinan : ………………………………………………
 Pengobatan yang didapat : ………………………………………………
d. Kala IV : ………………………………………………
Keadaan umum : ………………………………………………
TTV : : ………………………………………………
  Tekanan Darah : ………………………………………………
5  Nadi
 Respiratory Rate : ………………………………………………
 Suhu : ………………………………………………
TFU : ………………………………………………
Perdarahan : ………………………………………………
Perineum : ………………………………………………
Keadaan bayi
Berat badan / Panjang badan : ………………………………………………
Pusat : ………………………………………………
Perawatan tali pusat : ………………………………………………
Anus : ………………………………………………
Suhu : ………………………………………………
Lingkar kepala : : ………………………………………………
 Lingkaran Sub Occipito : ………………………………………………
Bregmatica (cm)
 Lingkaran Fronto Occipitalis (cm)
 Lingkaran mento Occipitalis (cm)
Kelainan kepala
Lain-lain
Pengobatan yang didapat

e. Rencana perawatan bayi

Kesanggupan dan pengetahuan
dalam merawat bayi :
 Breast care : ………………………………………………………….
 Perineal care : ………………………………………………………….
 Nutrisi : ………………………………………………………….
 Senam nifas : ………………………………………………………….
 KB : ………………………………………………………….
 Menyusui : ………………………………………………………….

2. RIWAYAT KELUARGA BERENCANA

Melaksanakan KB : ………………………………………………………….
Bila ya, jenis kontrasepsi yang digunakan : ………………………………………………………….
Sejak kapan menggunakan kontrasepsi : ………………………………………………………….
Masalah yang terjadi : ………………………………………………………….

3. RIWAYAT KESEHATAN
Penyakit yang pernah dialami ibu : ………………………………………………………….
Pengobatan yang didapat : ………………………………………………………….
Riwayat penyakit keluarga : ………………………………………………………….

4. RIWAYAT LINGKUNGAN
Kebersihan : ………………………………………………………….
Bahaya : ………………………………………………………….
Lainnya, sebutkan … : ………………………………………………………….

5. ASPEK PSIKOSOSIAL
Persepsi ibu setelah melahirkan : ……………………………………………….
Apakah keadaan ini menimbulkan perubahan : ……………………………………………….
terhadap kehidupan sehari-hari? ………………………………………………..
Bila ya, bagaimana? : ……………………………………………….
Harapan yang ibu inginkan setelah bersalin : ……………………………………………….
Ibu tinggal dengan siapa? : ……………………………………………….
Siapa orang yang terpenting bagi ibu? : ……………………………………………….
Sikap anggota keluarga terhadap keadaan saat ini : ……………………………………………….
Keadaan mental untuk menjadi ibu : ……………………………………………….

6. KEBUTUHAN DASAR KHUSUS

a Pola Nutrisi
Frekuensi makan : …………………………………………………….
Nafsu makan : …………………………………………………….
 Jenis makanan rumah : …………………………………………………….
Makanan yang tidak : ………………………………………………………….
disukai/alergi/makanan : ………………………………………………………….
b Pola Eliminasi
BAK : ………………………………………………………….
Frekuensi : ………………………………………………………….
Warna : ………………………………………………………….
Keluhan saat BAK : ………………………………………………………….
BAB : ………………………………………………………….
Frekuensi : ………………………………………………………….
Warna : ………………………………………………………….
Bau : ………………………………………………………….
Konsistensi : ………………………………………………………….
Keluhan saat BAB : ………………………………………………………….
c Pola Personal Hygiene
Mandi : ………………………………………………………….
Frekuensi : ………………………………………………………….
Sabun : ………………………………………………………….
Oral Hygiene : ………………………………………………………….
Frekuensi : ………………………………………………………….
Waktu : ………………………………………………………….
Cuci rambut : ………………………………………………………….
Frekuensi : ………………………………………………………….
Shampoo : ………………………………………………………….
d Pola Istirahat tidur
Lama tidur : ………………………………………………………….
Kebiasaan sebelum tidur : ………………………………………………………….
Keluhan : ………………………………………………………….
e Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ………………………………………………………….
Waktu bekerja : ………………………………………………………….
Olah raga : ………………………………………………………….
Kegiatan waktu luang : ………………………………………………………….
Keluhan dalam aktifitas : ………………………………………………………….

f Pola kebiasaan yang mempengaruhi

kesehatan : ………………………………………………………….
Merokok : ………………………………………………………….
Minuman keras : ………………………………………………………….
Ketergantungan obat

7. PEMERIKSAAN FISIK
Keadaan Umum
Kesadaran Compos mentis/apatis/delirium/somnolen/sopor/koma
GCS ..................................................................................
 Tekanan Darah : ………………………………………………………
 Nadi : ……………………………………………………….
 Frekuensi Pernapasan : ……………………………………………………….
 Suhu : ……………………………………………………….
Berat Badan / Tinggi badan : ……………………………………………………….
Kepala :
 Bentuk : ……………………………………………………….
 Keluhan : ……………………………………………………….
 Mata : ……………………………………………………….
 Kelopak Mata : ……………………………………………………….
 Gerakan mata : ……………………………………………………….
 Konjungtiva : ……………………………………………………….
 Sklera : ……………………………………………………….
 Pupil : ……………………………………………………….
 Akomodasi : ……………………………………………………….
 Lainnya, sebutkan : ……………………………………………………….
Hidung
 Reaksi alergi : ……………………………………………………….
  Sinus : ……………………………………………………….
 Lainnya, sebutkan : ……………………………………………………….
Mulut dan Tenggorokan
 Gigi geligi : ……………………………………………………….
 Kesulitan menelan : ……………………………………………………….
 Lainnya, sebutkan : ……………………………………………………….
Dada
 Mammae : ………………………………………………………
 Areola mammae : ………………………………………………………
 Papilla mammae : ……………………………………………………….
 Colostrum : ……………………………………………………….
Paru
 Inspeksi : ……………………………………………………….
 Palpasi : ……………………………………………………….
 Perkusi : ……………………………………………………….
 Auskultasi : ……………………………………………………….
Jantung
 Inspeksi : ……………………………………………………….
 Palpasi : ……………………………………………………….
 Perkusi : ……………………………………………………….
 Auskultasi : ……………………………………………………….
Abdomen
 Mengecil : ……………………………………………………….
 Linea & striae : ……………………………………………………….
 Luka bekas operasi : ……………………………………………………….
 TFU : ……………………………………………………….
 Kontraksi : ………………………………………………………
 Lainnya, sebutkan : ………………………………………………………..
Genitourinari
 Perineum : ……………………………………………………….
 Lochea : ……………………………………………………….
 Vesika urinaria : ……………………………………………………….
 Lainnya, sebutkan : ……………………………………………………….
Ekstremitas
 Turgor kulit : ……………………………………………………….
 Warna kulit : ……………………………………………………….
 Kontraktur pada persendian : ……………………………………………………….
ekstremitas
 Kesulitan dalam pergerakan : ……………………………………………………….
 Lainnya, sebutkan : ………………………………………………………

F. DATA PENUNJANG
Laboratorium
..............................................................................................................................................................................
..............................................................................................................................................................................
.....
USG
..............................................................................................................................................................................
..............................................................................................................................................................................
.....
Rontgen
............................................................................................................................................................................. .
..............................................................................................................................................................................
.....
Terapi yang didapat
..............................................................................................................................................................................
......................................................................................................................................... .....................................
.....

G. DATA TAMBAHAN
.....................................................................................................................................................................................
.....................................................................................................................................................................................
................................................................................................................................................................
ANALISA DATA
NO DATA PENYEBAB MASALAH
NO DATA PENYEBAB MASALAH

DIAGNOSA KEPERAWATAN

1. ...........................................................................................................................................................................

2. ............................................................................................................................................................................
3. ..............................................................................................................................................................................

4. ............................................................................................................................................................................

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

Ditemukan Teratasi
No. DIAGNOSA KEPERAWATAN
Tgl Paraf Tgl Paraf
 INTERVENSI KEPERAWATAN

No. DIAGNOSA TUJUAN & KRITERIA HASIL RENCANA KEPERAWATAN RASIONAL

KEPERAWATAN (NOC) (NIC)
No. DIAGNOSA TUJUAN & KRITERIA HASIL RENCANA KEPERAWATAN RASIONAL
KEPERAWATAN (NOC) (NIC)
No. DIAGNOSA TUJUAN & KRITERIA HASIL RENCANA KEPERAWATAN RASIONAL
KEPERAWATAN (NOC) (NIC)
No. DIAGNOSA TUJUAN & KRITERIA HASIL RENCANA KEPERAWATAN RASIONAL
KEPERAWATAN (NOC) (NIC)
 IMPLEMENTASI KEPERAWATAN

Tgl DIAGNOSA JAM IMPLEMENTASI PARAF

KEPERAWATAN

| 20
Tgl DIAGNOSA JAM IMPLEMENTASI PARAF
KEPERAWATAN

| 21
Tgl DIAGNOSA JAM IMPLEMENTASI PARAF
KEPERAWATAN

| 22
Tgl DIAGNOSA JAM IMPLEMENTASI PARAF
KEPERAWATAN

| 23
 CATATAN PERKEMBANGAN

NO DX HARI / TANGGAL
KEP

| 24
NO DX HARI / TANGGAL
KEP

| 25
NO DX HARI / TANGGAL
KEP

| 26
 EVALUASI KEPERAWATAN

Tgl DIAGNOSA EVALUASI Paraf

KEPERAWATAN
1. S : ………………………………………..

O : ……………………………………….

A: …………………………………………

P : ………………………………………..

2. S : ………………………………………..

O : ……………………………………….

A: …………………………………………

P : ………………………………………..

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Tgl DIAGNOSA EVALUASI Paraf
KEPERAWATAN
3. S : ………………………………………..

O : ……………………………………….

A: …………………………………………

P : ………………………………………..

4. S : ………………………………………..

O : ……………………………………….

A: …………………………………………

P : ………………………………………..

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