FORMAT ASUHAN KEPERAWATAN INTRANATAL.doc

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FORMAT ASUHAN KEPERAWATAN INTRANATAL ASUHAN KEPERAWATAN PADA Ny………………… DENGAN……………………………………................... DI RUANG …………………………………................... RS……………........................................................... TANGGAL …………………....................................... I.

PENGKAJIAN A. IDENTITAS PASIEN Nama

: ……………………………………………………

Umur

: ……………………………………………………

Pendidikan

:

…………………………………………………… Pekerjaan

: ……………………………………………………

Status Perkawinan : …………………………………………………… Agama

: ……………………………………………………

Suku

: ……………………………………………………

Alamat

: ……………………………………………………

No CM

: ……………………………………………………

Tanggal MRS

: ……………………………………………………

Tanggal Pengkajian : …………………………………………………… Sumber Informasi

: ……………………………………………………

Penanggung Jawab Nama

: ……………………………………………………

Umur

: ……………………………………………………

Pendidikan

:

…………………………………………………… Jenis kelamin

: ……………………………………………………

Pekerjaan

: ……………………………………………………

Alamat

: ……………………………………………………

Status perkawinan : …………………………………………………… Agama

: ……………………………………………………

B. DATA KESEHATAN a.

Keluhan Utama :

b.

Keluhan saat dikaji :

c.

Riwayat keluhan (kaji data mulai dari timbulnya keluhan sampai dengan dilakukan asuhan keperawatan)

RIWAYAT OBSTETRI DAN GINEKOLOGI 1.Riwayat Menstruarsi : 

Menarche : umur …..

Siklus :



Banyaknya :….

Lama :………



Keluhan :………



HPHT :………..

teratur ( ) tidak ( )

2.Riwayat Pernikahan a. Menikah : ….kali

Lama : ….tahun

b. Riwayat kehamilan, persalinan, nifas yang lalu : Anak

Kehamilan

Persalinan

Komplikasi nifas

Anak

Ke N T

Umur

Peny

jen penol

Peny

Laser infe

Perdara Jenis

B

P

o

keham

ulit

is

ulit

asi

han

B

j

hn

ong

ilan

ksi

Kela min

c. Riwayat kehamilan saat ini Status Obstetrikus : 

G…P…A…H…



TP : ….



ANC kehamilan sekarang :………...........................................

UK : ……..minggu

Trimester I :………………………………………………………… Trimester II : ……………………………………………………..... Trimester III : …………………………………………………….... d. Riwayat keluarga berencana 

Akseptor KB

: …...



Jenis

: ……



Lama

: ………



Masalah

: ……

D. RIWAYAT PENYAKIT i. Klien

:…………

ii. Keluarga

: …………

E. POLA FUNGSIONAL KESEHATAN 1. Pola Manajemen Kesehatan-Persepsi Kesehatan ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 2. Pola Metabolik-Nutrisi ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 3. Pola Eleminasi ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 4. Pola Aktivitas-Latihan ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 5. Pola Istirahat-Tidur ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 6. Pola Persepsi-Kognitif ....................................................................................................... .......................................................................................................

....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 7. Pola Konsep Diri-Persepsi Diri ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 8. Pola Hubungan-Peran ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 9. Pola Reproduktif-Seksualitas ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 10. Pola Toleransi Terhadap Stres-Koping ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... 11. Pola Keyakinan-Nilai ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... G. PEMERIKSAAN FISIK Keadaan umum : 

GCS

: E..…….....….V.....................M...................



Tingkat kesadaran

: ………………….........................................



Tanda – tanda vital

: TD….............N….........RR….........T…......



BB

: ………….TB:………… LILA :………..

Head toe toe :  Kepala wajah : Pucat ( ) Cloasma ( ) sklera : konjungtiva : pembesaran limphe node pembesaran kelenjar tiroid : telinga : ………………………………………  Dada Payudara Areola :…………….. Putting : (menonjol / tidak ) Tanda dimpling / retraksi :………………… Pengeluaran ASI : ……………….. Jantung : ………. Paru : …………..  Abdomen Linea : …… Striae :………… Pembesaran sesuai UK : …………. Gerakan Janin : ………….. Kontraksi : ……. Luka bekas operasi : ………….. Ballottement : ………………………. Leopold I : Kepala / bokong / kosong TFU:……............. Leopold II : Kanan : punggung/bagian kecil/bokong /kepala Kiri : punggung / bagian kecil /bokong/kepala Leopold III : Presentasi kepala / bokong/kosong Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar) Penurunan kepala : .........(penurunan bag.terbawah dengan metode lima jari ) Kontraksi : …………………. DJJ :………………….. Bising usus : …………………..  Genetalia dan perineum : Kebersihan :…………… Pengeluaran :…………………. Karakteristik :…………….. Hasil VT : ……………………………………………………………….

Hemoroid  Ekstremitas Atas Oedema Varises CRT Bawah Oedema Varises CRT Refleks

:…………………

:………………....................................................… :………………….................................................... :………………….................................................... :………………….................................................... :………………….................................................... :………………….................................................... :……………….......................................................

G. DATA PENUNJANG  Pemeriksaan Laboratorium

:………………………..

 Pemeriksaan USG

:………………………..

H. DIAGNOSA MEDIS

I. PENGOBATAN

II.

ANALISA DATA KALA I DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas : 1. 2. 3. 4. 5.

II.

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

RENCANA KEPERAWATAN KALA I No

Tgl /

Nomor

jam

Diagnosa

Tujuan

Rencana Keperawatan Intervensi

Rasional

SMART :

IV. IMPLEMENTASI KALA I Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

V.EVALUASI KALA I

Tgl/Jam

No Dx

Evaluasi Hasil

Paraf

KALA II A. DATA FOKUS KALA II

B. ANALISA DATA KALA II DATA FOKUS

ANALISIS

MASALAH

Diagnosa keperawatan berdasarkan prioritas : 1. 2. 3. 4. 5.

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

C. RENCANA KEPERAWATAN KALA II N

Tgl /

Nomor

o

jam

Diagnosa

Rencana Keperawatan Tujuan Intervensi Rasional SMART tulis

: Tulis NIC

NOC Nursing

yang sesuai activities disertai dengan indicator capaian

D. IMPLEMENTASI KALA II

Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

E. EVALUASI KALA II Tgl/Jam

No Dx

Evaluasi Hasil

Paraf

KALA III F. DATA FOKUS KALA III

G. ANALISA DATA KALA III DATA FOKUS

ANALISIS

Diagnosa keperawatan berdasarkan prioritas :

MASALAH

1. 2. 3. 4. 5.

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

H. RENCANA KEPERAWATAN KALA III N

Tgl /

Nomor

o

jam

Diagnosa

Rencana Keperawatan Tujuan Intervensi Rasional SMART tulis

: Tulis NIC

NOC Nursing

yang sesuai activities disertai dengan indicator capaian

I.

IMPLEMENTASI KALA III Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

J. EVALUASI KALA III

Tgl/Jam

No Dx

Evaluasi Hasil S : data subyektif O : data obyektif A : Analisis apakah tujuan tercapai atau tidak dengan hasil : tercapai (semua indicator tercapai) sebagian (satu atau lebih indicator tercapai dan tidak tercapai (semua indicator tidak tercapai) P :dianalis semua aspek asuhan (diagnose

keperawatan,

implementasi, intervensi, NOC dan waktu) Perencanaan dilanjutkan atau dimodifikasi

perencanaan

mengacu pada hasil.

Paraf

Tgl/Jam

No Dx

Evaluasi Hasil S: O: A: P:

KALA IV A. DATA FOKUS KALA IV

B. ANALISA DATA KALA IV DATA FOKUS DS :

ANALISIS Analisis dengan

DO :

pohon masalah

MASALAH

Diagnosa keperawatan berdasarkan prioritas : 1. 2. 3. 4. 5.

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

B. RENCANA KEPERAWATAN KALA IV N o

Tgl / jam

Nomor Diagnosa

Tujuan SMART tulis

Rencana Keperawatan Intervensi Rasional : Tulis NIC

NOC Nursing

yang sesuai activities disertai dengan indicator capaian

D. IMPLEMENTASI KALA IV Tgl/Jam

No.Dx

Implementasi

Respon

Paraf/Nama

A. EVALUASI KALA IV

Tgl/Jam

No Dx

Evaluasi Hasil S : data subyektif

Paraf

O : data obyektif A : Analisis apakah tujuan tercapai atau tidak dengan hasil : tercapai (semua indicator tercapai) sebagian (satu atau lebih indicator tercapai dan tidak tercapai (semua indicator tidak tercapai) P :dianalis semua aspek asuhan (diagnose

keperawatan,

implementasi, intervensi, NOC dan waktu) Perencanaan

dilanjutkan

atau

dimodifikasi perencanaan mengacu pada hasil.

Denpasar, …………………….20…..

Mengetahui Pembimbing Klinik/ CI

Mahasiswa

(……………………........................….)

(……………......................

…………….) NIP:

NIM:

Clinical Teacher/CT 1

(……..…………….....................................................) NIP:

FORMAT ASUHAN KEPERAWATAN BAYI BARU LAHIR ASUHAN KEPERAWATAN PADA By.................. DENGAN......................................... DI RUANG.......................... RS……………………….. TANGGAL.......... I

PENGKAJIAN i. IDENTITAS PASIEN Nama

:

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

Umur

:

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

Nama Ayah-Ibu

:

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

Umur

:

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

Pendidikan

:

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

Pekerjaan

:

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

ii. No

Status perkawinan :

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

Agama

:

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

Suku

:

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

Alamat

:

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

No.CM

:

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

Tanggal MRS

:

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

Tanggal pengkajian :

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

Sumber informasi

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

:

RIWAYAT KELAHIRAN

Tahun

Jenis

kelahiran

kelamin

BB lahir

Keadaan bayi

Komplikasi

Jenis persalinan

Ket

iii.

RIWAYAT PERSALINAN BB/TB Ibu : ............kg/................cm

Persalinan di...............

Keadaan umum Ibu .........................

Tanda vital .................

Jenis persalinan ...............................

Proses persalinan.......

Kala I.................................Jam Indikasi : ..........................................

Kala II .......................menit Komplikasi persalinan : Ibu.................................

Janin ........................

Lamanya ketuban pecah ...................................... Kondisi ketuban.... IV.

KEADAAN BAYI SAAT LAHIR Lahir tanggal

: ...................jam............

Kelahiran

: Tunggal/gemeli

Jenis kelamin.............

Nilai APGAR Tanda Denyut

0 Tidak ada

Nilai 1 < 100

>100

jantung Usaha napas

Tidak ada

Lambat

Menangis

Lumpuh

Ekstremitas

kuat Gerakan aktif

Iritabilitas

Tidak

fleksi sedikit Gerakan

Reaksi

reflex Warna

bereaksi Biru/pucat

sedikit Tubuh

melawan Kemerahan

Tonus otot

Jumlah 2

kemerahan, tangan kaki biru V.

PENGKAJIAN FISIK Umur ..............Hari....................Jam.......... Berat badan.................................gr Panjang badan.............................cm Suhu...........................................ºC Lingkar kepala.............................cm Lingkar dada...............................cm

dan

Lingkar perut..............................cm Head to toe Kepala Wajah o Inspeksi : ............................................................. o Palpasi

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

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

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

Tubuh o Warna

:……………………………………………

o Lanugo

:……………………………………………

o Vernix

:……………………………………………

Dada o Inspeksi

:

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

o Palpasi

:

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

o Perkusi

:

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

o Auskultasi : ………….............................................. Abdomen

o Inspeksi

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

o Auskultasi : ............................................................ o Perkusi

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

o Palpasi

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

Punggung o Keadaan punggung

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

o Fleksibilitas

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

o Tulang punggung

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

o Kelainan

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

Genetalia dan anus o Laki-laki

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

o Perempuan

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

o Anus

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

o Mekonium

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

o Kelainan

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

Ekstremitas o Atas

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

o Bawah

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

o Kelainan : ............................................................. o Pergerakan : ........................................................... VI.

STATUS NEUROLOGI Pemeriksaan refleks : .................................................

VII.

NUTRISI ASI/PASI/Lain-lain

VIII.

ELIMINASI BAB pertama, tanggal ........................ Jam.................. BAK pertama, tanggal ........................ Jam..................

IX .

DATA PENUNJANG o Pemeriksaan Laboratorium :…………………………..

o Pemeriksaan Diagnostik X.

:…………………………..

DIAGNOSA MEDIS ……………………………………………………………………………………………… ………………………………………………………………………………………………

XI. PENGOBATAN

B. ANALISA DATA DATA FOKUS

ANALISIS

MASALAH

DS :

DO :

Analisis dengan pohon masalah

Diagnosa keperawatan berdasarkan prioritas : 1.

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

2.

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

3.

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

C. RENCANA KEPERAWATAN

IV. IMPLEMENTASI Tgl/

No.

Jam

Dx

Implementasi

Respon

Paraf/Nama

V. EVALUASI

Tgl/Jam

No

Evaluasi Hasil

Dx S=

O=

A=

Paraf

P=

S=

O=

A=

P=

Denpasar, …………………….2017 Mengetahui Pembimbing Klinik/ CI

Mahasiswa

(………………………................)

(…….........…………………….)

NIP:

NIM:

Clinical Teacher /CT

(...................................................................) NIP.

FORMAT ASUHAN KEPERAWATAN INTRANATAL.doc

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