Date post: | 07-Jul-2018 |
Category: |
Documents |
Upload: | ni-made-dwi-yuliantini |
View: | 226 times |
Download: | 0 times |
of 37
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
1/37
ASUHAN KEPERAWATAN
PADA PASIEN “Ny.U” DENGAN POST PARTUS SPONTAN
DI RUANG BAKUNG RSU NEGARATGL 10 s/d 11 SEPTEMBER 2013
OLEH :
I GST AU PUTU WIWIEK PEBRONITA
!P0"12001111#)
POLTEKKES KEMENKES DENPASAR
PROGSUS DIII KEPERAWATAN RSU NEGARA
TAHUN 2012/2013
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
2/37
LAPORAN PENDAHULUAN POST PARTUM !NI$AS%
I. KONSEP DASAR PENAKIT
A. P&'(&)*+,'1. Masa nifas ata !"#!"#i$ a%a&a' %i$&ai s"(a 1 (a$ s"t"&a' &a'i#n*a
!&as"nta sa$!ai %"n+an , $in++ -2 'a#i) s"t"&a' it. Masa !asa
!"#sa&inan a%a&a' fas" 'ss %a&a$ "'i%!an i s"#ta a*i. T"#(a%i
!"#a'an "'i%!an *an+ "#$ana s"!"#ti !"#a'an "$sina&
!"#a'an fisi 'n+an "&a#+a %an !"n*"saian t"#'a%a! at#an *an+
a# -Ha%i(n 200).
2. P"#!"#i$ / nifas a%a&a' $asa s"s%a' !"#sa&inan %i$&ai s"t"&a'
"&a'i#an !&as"nta %an "#a'i#n*a "tia a&at4a&at an%n+an "$a&i
s"!"#ti "a%aan s""&$ 'a$i& $asa nifas "#&an+sn+ s"&a$a ± , $in++
-P"&a*anan K"s"'atan Mat"#na& %an N"nata&2002)
B. K-,s++,s+
Masa nifas %ia+i %a&a$ ti+a !"#i%" *ait 5
1. P&)&)+ d+'+ a%a&a' n%isi "!&i'an %i$ana s"#an+ i s%a'
%i!"#&"'an "#%i#i %an "#(a&an
2. P&)&)+ I'*&)&d+,- ,d,-, 4'd+s+ &-+,' 4)(,' (&'+*,-
s&5,), &'y&-) d&'(,' -,, 678 +'((
3. R&4*& P&)&)+ a%a&a' 6at *an+ %i!"#&an nt !&i' %an s"'at
s"$!#na t"#ta$a i&a saat 'a$i& ata 6at !"#sa&inan $"n+a&a$i
$!&iasi.
9. G&,-, K-+'+s !$+s+4-4(+s N+,s%
1. P&);,,' $+s+
,. S+s*& R&)4ds+1) Ut"#s
S"a#a "#an+s#4an+s# n%isi t"#s aan $"$ai %"n+an
!"n+"i&an #an -in7&si) %a#i t"#s it s"n%i#i. A%a!n tin++i
fn%s t"#i -T8U) !st !a#t$ $"n#t $asa in7&si5
Ta"& 1. T8U $"n#t $asa in7&si
IN
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
3/37
Int"nsitas nt#asi t"#s $"nin+at s"a#a "#$ana s"+"#a
s"t"&a' a*i &a'i#. S"&a$a 1 sa$!i 2 (a$ !"#ta$a !asa!a#t$
int"nsitas nt#asi t"#s isa "##an+ %an $"n(a%i ti%a
t"#at#. Ka#"na !"ntin+ s"a&i nt $"$!"#ta'anan nt#asi
t"#s s"&a$a $asa ini iasan*a sntian sitsin s"a#a I; ata
IM %i"#ian s"+"#a s"t"&a' !&as"nta &a'i#. I *an+ $"#"nanaan
$"n*si a*in*a %ian(#an $"$ia#an a*in*a %i !a*%a#a
s"+"#a s"t"&a' &a'i# a#"na isa!an a*i !a%a !a*%a#a $"#an+san+
!"&"!asan sitsin.
2)
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
4/37
a) L45&, );),5 "#isi %a#a' s"+a# %an sisa > sisa s"&a!t
"tan t"#(a%i s"&a$a 2 'a#i !asa !"#sa&inan
) L45&, S,'(+'4-&'*,5 "#6a#na $"#a' nin+ "#isi %a#a'
%an &"n%i# t"#(a%i 'a#i " 3 > = !asa !"#sa&inan) L45&, s&)4s,5 K"&a# ai#an ti%a "#isi %a#a' "#6a#na
nin+. T"#(a%i 'a#i " = > 1 'a#i !asa !"#sa&inan
%) L45&, ,-;,5
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
5/37
an"st'"sia %an "&"ti'an "an*aan i $"#asa san+at &a!a#.
P"#$intaan nt $"$!"#&"' $aanan %a a&i %a#i ($&a' iasa
%ins$si %is"#ta ns$si a$i&an *an+ s"#in+ %it"$an.
2) Mti&itas
S"a#a 'as !"n#nan tns %an $ti&itas tt t#ats "#na
$"n"ta! s"&a$a 6at *an+ sin+at s"t"&a' a*i &a'i#. K"&"i'an
ana&+"sia %an anst'"sia isa $"$!"#&a$at !"n+"$a&ian tns
%an $ti&itas " "a%aan n#$a&.
3) D"f"asi
9an+ ai# "sa# s"a#a s!ntan isa t"#tn%a s"&a$a %a sa$!ai
ti+a 'a#i s"t"&a' i $"&a'i#an. K"a%aan ini isa %is"aan
a#"na tns tt ss $"n#n s"&a$a !#s"s !"#sa&inan %an !a%a
a6a& $asa !asa!a#t$ %ia#" s""&$ !"#sa&inan "n"$a s""&$
$"&a'i#an #an+ $aan ata %"'i%#asi.. K"iasan an+ ai#
*an+ t"#at# !"#& %ia!ai "$a&i s"t"&a' tns ss "$a&i
n#$a&.
d. S+s*& P&)&+,'
T#a$a isa t"#(a%i !a%a #"t#a %an an%n+ "$i' s"&a$a !#s"s
$"&a'i#an *ani s"6at a*i $"&"6ati (a&an &a'i#. Din%in+ an%n+
"$i' %a!at $"n+a&a$i 'i!"#"$is %an "%"$a s"#in+a&i %is"#ti
%a"#a'4%a"#a' "i& '"$#a+i. P"n+a$i&an #in" %"n+an a#a "#si'
ata $"&a&i at"t"# s"#in+ $"nn(an a%a*a t#a$a !a%a an%n+
"$i'. U#"t#a %an $"ats #ina#is isa (+a $"n+a&a$i "%"$a.
&. S+s*& I'*&(&'
Hi!"#!i+$"ntasi %i a#"&a %an &in"a ni+#a ti%a $"n+'i&an+ s"&#'n*a
s"t"&a' a*i &a'i#. K&it *an+ $"#"+an+ !a%a !a*%a#aa%$"n !a'a
%an !an++& $n+in $"$%a# t"ta!i ti%a 'i&an+ s"&#'n*a.
K"&ainan !"$&' %a#a s"!"#ti s!i%"# an+i$a -n"7i) "#it"$a !a&$a#
iasan*a "##an+ s"a+ai #"s!n t"#'a%a! !"n#nan a%a# "st#+"n
s"t"&a' "'a$i&an "#a'i#. Diaf#"sis a%a&a' !"#a'an *an+ !a&in+
("&as t"#&i'at !a%a sist"$ int"+$"n.
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
6/37
2. P&);,,' Ps+4-4(+s
A%a 3 fas" %a&a$ !si&+is i *ait5
,. $,s& *,+'( +'
P"#'atian i t"#ta$a t"#'a%a! "t'an %i#in*a $n+in !asif %an
t"#+antn+ "#&an+sn+ 142 'a#i.
;. $,s& *,+'( 4-d
I $"na $an%i#i %an "#inisiatif. P"#'atian t"#'a%a! "$a$!an
$"n+atasi fn+si t'n*a $isa&n*a "&ana#an 9AK 9A9 %an
"$a$!an $"&aan ati7itas !"#a6atan %i#i.
5. $,s& -&**+'( (4
T"#(a%i !"nin+atan "$an%i#ian %a&a$ !"#a6atan %i#i s"n%i#i %an
a*in*a !"n*"saian %a&a$ 'n+an "&a#+a t"#$as a*i.
D. P&&)+s,,' P&'','(
1 Da#a' &"n+a! -H Ht L"sit t#$sit)
2 U#in" &"n+a!
E. P&&)+s,,' D+,('4s*+
PEMERIKSAAN DIAGNOSTIK HASIL
Kn%isi t"#s5 !a&!asi fn%s nt#asi
fn%s t"#i.
Knt#asi $i$"t#i$ tin+at in7&si t"#i.
?$&a' !"#%a#a'an ins!"si !"#in"$&as"#asi %an '"$at$a
9"nt insisi %an "%"$a
P"n+"&a#an &'"a R#a s"#sa %an a&a.
Kan%n+ "$i'5 %ist"nsi &a%%"# H"$at#i!#t"in #ia a"tn#ia
Tan%a4tan%a 7ita&5 s' 1 (a$ !"#ta$a s"ta&a' !st !a#t$ TD %an na%i t"#'a%a! !"n*i$!an+an a#%i7as&a#
2 (a$ !"#ta$a @ 30
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
7/37
. ,4 (a$ !asa !"#sa&inan5 isti#a'at %an ti%# t"nan+ sa'aan $i#in+
anan i#i
. Ha#i "4 1425 $"$"#ian KIE ""#si'an %i#i a#a $"n*si *an+ "na#
%an !"#a6atan !a*%a#a !"#a'an4!"#a'an *an+ t"#(a%i !a%a $asa
nifas !"$"#ian inf#$asi t"ntan+ s"na$ nifas.
%. Ha#i "4 25 $&ai &ati'an %%
". Ha#i "4 35 %i!"#"nanan &ati'an "#%i#i %an "#(a&an
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
8/37
II. KONSEP DASAR ASUHAN KEPERAWATAN
A. PENGKA=IAN
1. Id&'*+*,s
M"&i!ti i%"ntitas &i"n *an+ t"#%i#i %a#i na$a $# a&a$at stats
!"#a6inan. T"#%a!at (+a i%"ntitas !"nan++n+ $isa& sa$i.
2. S*,*s K&s&,*,' S,,* I'+
M"&i!ti "&'an saat MRS %an "&'an ta$a saat ini.
3. R+>,y,* O;s*&*)+
a. Ri6a*at $"nst#asi
. Ri6a*at "'a$i&an !"#sa&inan nifas *an+ &a&
#. R+>,y,* P&)s,-+',' d,' K&-,+),' S,,* I'+
a. Ti!" !"#sa&inan
. La$a !"#sa&inan -a&a I a&a II a&a III a&a I;)
. P"n++naan ana&+"si %an anast"si
%. A!aa' t"#%a!at $asa&a' %a&a$ !"#sa&inan.
". K"san++!an %an !"n+"ta'an %a&a$ !"#a6atan a*i s"!"#ti #"ast a#"
!"#in"a& a#" nt#isi s"na$ nifas K9 $"n*si
?. K&,d,,' B,y+
M"&i!ti 99 P9 a!aa' a%a "&ainan ata ti%a.
6. R+>,y,* K&-,)(, B&)&'5,',
A!aa' &i"n $"&asanaan K9
a. 9i&a *a ("nis nt#as"!si a!a *an+ %i+naan.
. S%a' "#a!a &a$a $"n++naan nt#as"!si.
. A!aa' t"#%a!at $asa&a' %a&a$ !"n++naan nt#as"!si.
". R+>,y,* K&s&,*,'
a. P"n*ait *an+ !"#na' %ia&a$i &i"n.
. P"n+atan *an+ !"#na' %i%a!at.
. A!aa' a%a #i6a*at !"n*ait "&a#+a s"!"#ti !"n*ait %ia"t"s $"&&its
!"n*ait (antn+ !"n*ait 'i!"#t"nsi.
8. K&;*,' D,s,) Kss
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
9/37
a. P&a nt#isi.
Nafs $aan $"nin+at K"'i&an+an #ata4#ata "#at a%an :: +.
. P&a "&i$inasi/sist"$ #+"nita&.
1) Knsti!asi ti%a $a$! "#"$i' #"t"nsi #in".
2) E%"$a !a%a an%n+ "$i' #"t'#a %an $"ats #ina#is t"#(a%i
a#"na t#a$a.
3) Pa%a fn+si +in(a&5 !#t"in#ia %i#"sis $&ai 12 (a$.
) 8n+si "$a&i n#$a& %a&a$ $in++.
. P&a !"#sna& '*+i"n".
9a+ai$ana f#""nsi !"#sna& '*+i"n" &i"n s"!"#ti $an%i #a&
'*+i"n" $a!n si #a$t.
%. P&a isti#a'at %an ti%#.
K#an+ ti%# $"n+ant.
". P&a ati7itas %an &ati'an.
T"#+an++ a#"na n*"#i.
f. P&a "iasaan *an+ $"$!"n+a#'i "s"'atan
A!aa' &i"n $"# $in$4$in$an "#as ata!n
"t"#+antn+an at.
+. S"sa&itas/#"!#%si
K"tatan $"&aan 'n+an s"sa& a#"na n*"#i.
'. P"#an
P"#a'an !"#an s"a+ai i.
i. P"#s"!si %i#i/ns"! %i#i
P"ni&aian it#a t' t"#+an++.
(. K+nitif !"#"!ta&K#an+ !"n+"ta'an t"ntan+ !"#a6atan a*i i !st !a#t$.
@. P&&)+s,,' $+s+
a. K&,d,,' Umum
1) G
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
10/37
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
11/37
K"$a&i " !sisi n#$a&
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
12/37
S"+"#a s"t"&a' &a'i# t"#(a%i "%"$a "nt %ist"nsi nt
""#a!a 'a#i st#t# int"#na& "$a&i %a&a$ 2 $in++ st#t#
"st"#na& $"&"a# %an ta$!a "#"&a'.
) ;a+ina
Na$!a "#+a" "$a&i !a%a 3 $in++ "$a&i $"n%"ati
#an s"!"#ti ti%a 'a$i& %a&a$ , sa$!ai $in++ "nt
#a$!in+ &"a# !#%si $s n#$a& %"n+an 7&asi.
:) P"#ini$ %an Ans
a) P"$"#isaan !"#in"$ 5 REEDA -#"% "%"$a "'*$sis
%is'a#+" &ss f a!!#i$atin)
) P"$"#isaan a%an*a '"$#i%.
. Es*)&+*,s
1) M"$"#isa a!aa' tan+an %an ai "%"$a !at !a%a (a#i
'an+at a%an*a n*"#i %an "$"#a'an.
2) A!aa' a%a 7a#is"s.
3) M"$"#isa #"f&"s !at"&&a nt $"n+"ta'i a!aa' t"#(a%i '*!
ata '*!"#.
) M"$"#isa '$ansB si+n -n*"#i saat ai %#sf&"si !asif).
10. P&);,,' Psikologis
1 P"#an I $"&i!ti5
Kn%isi I n%isi a*i fat# ssia&4"n$i fat# "&a#+a sia
i nf&i !"#an.
2 9a* 9&"s5M&ai t"#(a%in*a a%aa' ani"tas $a#a' #"s!n %"!#"si %an !sisis.
3 P"#a'an Psi&+is
1) P"#a'an !"#an s"a+ai #an+ ta.
2) Atta'$"nt *an+ $"$!"n+a#'i %a#i fat# i a*a' %an a*i.
3) 9a* 9&"s $"#!aan +an++an !"#asaan *an+ $"n"ta!
iasan*a !a%a 'a#i III %i$n+inan a#"na t#nn*a '#$n
"st#+"n %an !"#+"s"#an *an+ $"$!"n+a#'i "$si i.
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
13/37
B. DIAGNOSA KEPERAWATAN
1. Risi %"fisit 7&$" ai#an /% !"n+"&a#an *an+ "#&"i'anC !"#%a#a'anC
%i#"sisC "#in+at "#&"i'an.
2. P"#a'an !&a "&"$inasi 9AK -%is#ia) /% t#a$a !"#in"$ %an sa&#an
"$i'.
3. P"#a'an !&a "&"$inasi 9A9 -nsti!asi) /% #an+n*a $i&isasiC %i"t
*an+ ti%a s"i$an+C t#a$a !"#sa&inan.
. N*"#i at /% !"#"+an+an !"#in"$C &a "!isit$iC in7&si t"#iC
'"$#i%C !"$"n+aan !a*%a#a.
:. Risi inf"si /% t#a$a (a&an &a'i#.
,. Risi +an++an !#s"s !a#"ntin+ /% #an+n*a !"n+"ta'an t"ntan+ a#a
$"#a6at a*i.
=. Gan++an !"$"n'an ADL /% "&"$a'anC "&"&a'an !st !a#t$.
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
14/37
9. REN9ANA KEPERAWATAN
1
D
2
T
3 R&'5
,',
I'*&)
&'s+
# R,s+4',-
?
1
6
2
" 3 8 #
R
10
11S"
1. TT; %a&a$ atas n#$a&2. TD 5 ,040/110410
$$H+3. Na%i 5 ,04100 /$"nit
. S' 5 3,:43=:<
:. RR 5 1,42 /$"nit,. Ti%a a%a tan%a4tan%a
%"'i%#asi -$sa ii# &"$a t#+# &it
ai)
=. Ha&a#an #in" 0:41$&/+ 99/(a$
12
4 PantaTan%a4tan%a 7ita& s"tia! (a$.
4 M"n+i%"ntifiasi "a%aan $$ !asi"n s"#taa%an*a !"n*i$!an+an in%iasi "$a(an ata
!"n*i$!an+an %a#i 'asi& *an+ %i'a#a!an.13
4 Panta ai#an $as %an ai#an
"&a# s"tia! (a$.
4 M"n+i%"ntifiasi "s"i$an+an ai#an !asi"n
s"a#a a%"at %an t"#at#.1,
4 Os"#7asi "tat 2 (a$ !st !a#t$
-a%an*a $!&iasi !"#%a#a'an)
1
4 Os"#7asi ai %i&aan nt $"n"+a'
t"#(a%in*a "$n+inan *an+ ti%a %iin+inan
s"!"#ti a%an*a !"#%a#a'an !st !a#t$20
4 Ka(i a%an*a tan%a4tan%a %"'i%#asi
-$sa ii# %an t#+# &it)
23
4 S"a+ai %"t"si a6a& %a#i "#an+an ai#an
2
4 9"#ita' %t"# i&a5 t"#(a%i
taia#%ia s"&a& $"#asa 'as+"&isa' TD %i a6a' #"ntan+
n#$a& #in" +"&a! ata "n"# +"&a!.
2=
4 T"$an4t"$an ini $"nan%aan 'i!7&"$ia
%an !"#&n*a !"nin+atan ai#an.
2P
2
30 S"t"&a'%i&aan tin%aan"!"#a6atan s"&a$a
. . %i'a#a!an
!&a "&"$inasi-9AK) !asi"n
t"#at# %"n+an#it"#ia 'asi&5
4 Ka(i 'a&a#an #in" "&'an s"#ta"t"#at#an !&a "#"$i'.32
4 M"n+i%"ntifiasi !"n*i$!an+an %a&a$ !&a "#"$i' !asi"n.33
4 An(#an !asi"n $"&aana$&asi %ini.
3,
4 A$&asi %ini $"$"#ian #an+san+an nt !"n+"&a#an #in" %an !"n+sn+an &a%%"#.
4 An(#an !asi"n nt $"$asa'i
!"#in"$ %"n+an ai# 'an+at
4 M"$asa'i &a%%"# %"n+an ai# 'an+at %a!at
$"n+#an+i "t"+an+an aiat a%an*a &a !a%a
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
15/37
1. E&"$inasi 9AK &ana#
-6a#na "("#ni'an7&$" #in" *an+ "&a#
%a&a$ atas n#$a& )2. Ti%a a%a %is#ia
3. K"&'an "nin+ ti%a
a%a.31
s""&$ "#"$i'.
3
&a%%"#.
4 An(#an !asi"n nt "#"$i'
s"a#a t"#at#.
4 M"n"#a!an !&a "#"$i' s"a#a t"#at# aan
$"&ati' !"n+sn+an &a%%"# s"a#a t"#at#.
4 An(#an !asi"n nt $in$2:0043000 $&/2 (a$.
4 Min$ an*a $"$!"#"!at f i& t#asi !a%a+&$"#&s %an $"$!"#"!at !"n+"&a#an #in"
:
4 Tan*aan !a%a !asi"n $"n+"nai
a%an*a "&'an %a&a$ "#"$i'
4 Unt $"n"ta!an int"#7"nsi "!"#a6atan *an+
t"!at a+i !asi"n
4 K&a#asi nt $"&aanat"t"#isasi i&a !asi"n "s&itan
"#"$i'.
:1
4 Kat"t"#isasi $"$ant !"n+"&a#an #in" nt $"n"+a' stasis #in"
:2P
:3
: S"t"&a' %i&aantin%aan "!"#a6atan s"&a$a
%i'a#a!an !&a
"&"$inasi -9A9) !asi"nt"#at# %"n+an #it"#ia 'asi& 5
P&a "&"$inasi t"#at# -ti%a a%an*a nsti!asi)
8"s"s &na %an 6a#na
'as f"s"s -ti%a "#a$!# %a#a' %an
&"n%i#)9a 'as f"s"s
Ti%a a%a
"s&itan/"&'an 9A9
::
4 Ka(i !&a %an f#""nsi 9A9"s&itan 9A9 6a#na a %an
nsist"nsi f"s"s s"#ta "&'an
%a&a$ $"&aan 9A9:,
4 M"n+i%"ntifiasi !"n*i$!an+an s"#ta "$a(an%a&a$ !&a "&"$inasi -9A9).
4 An(#an a$&asi %ini. Ha#i "4 25
$&ai &ati'an %% Ha#i "4 35
%i!"#"nanan &ati'an "#%i#i %an "#(a&an
:
4 A$&asi %ini $"#an+san+ !"n+sn+an #"t$
s"a#a &"i' "!at.
4 An(#an !asi"n nt $in$
an*a 2:0043000 $&/2 (a$.
4
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
16/37
sa*#4sa*#an 'i(a.
=1=2
=3
=
G
=:
=, S"t"&a'
%i&aan tin%aan"!"#a6atan s"&a$a
%i'a#a!an
ADL %an "t'an "#atifitas !asi"n
t"#!"n'i s"a#aa%"at %"n+an
#it"#ia 'asi&5
Pasi"n $"nn(an !"nin+atan %a&a$
"#atifitas.K"&"$a'an %an "&"&a'an
"##an+.K"t'an ADL t"#!"n'i
s"a#a $an%i#i ata
%"n+an antan.8#""nsi na%i / i#a$a
(antn+ s"#ta t"anan%a#a' %a&a$ atas n#$a&
-TDF100410/,040
$$H+ NF,04100/$"nit)
==
4 Ka(i t&"#ansi !asi"n t"#'a%a!
atifitas $"n++naan !a#a$"t"# "#it5 atat !"nin+aatan TD
%is!n"a n*"#i %a%a "&"&a'an
"#at "&"$a'an "#"#in+at !sin+ ata !in+san.
4 Pa#a$"t"# $"nn(an #"s!n fisi&+is !asi"n
t"#'a%a! st#"s atifitas %an in%iat# %"#a(at !"n+a#' "&"i'an "#(a (antn+.
4 Tin+atan isti#a'at atasi atifitas !a%a %asa# n*"#i/#"s!n
'"$%ina$i 0
4 M"n#nan "#(a $ia#%/$s$si si+"n $"n#nan #"si $!&iasi.
1
4 9"#ian atifitas s"n++an+ *an+
ti%a "#at.
4 Stai&itas fisi&+is !a%a isti#a'at !"ntin+ nt
$"nn(an tin+at atifitas in%i7i%.
4 Ka(i "sia!an nt $"nin+atan
atifitas nt'5 !"n#nan"&"$a'an/"&"&a'an TD
stai&/f#""nsi na%i !"nin+atan !"#'atian !a%a atifitas %an
!"#a6atan %i#i.
=
4 Kns$si si+"n $ia#%ia s"&a$a "#a+ai
atifitas %a!at $"nin+atan ($&a' si+"n*an+ a%a. K"$a(an atifitas "#ta'a! $"n"+a'
!"nin+atan tia4tia !a%a "#(a (antn+.
4 D#n+ $"$a(anatifitas/t&"#ansi !"#a6atan %i#i.
4 T"ni !"n+'"$atan "n"#+i $"n#nan !"n++naan "n"#+i %an $"$ant "s"i$an+an
s!&ai %an "t'an si+"n.
4 An(#an "&a#+a nt $"$ant
!"$"n'an "t'an ADL !asi"n.
4 Atifi tas *an+ $a( $"$"#ian nt#&
(antn+ $"nin+atan #"+an+an %an $"n"+a'atifitas "#&"i'an.
2
3
N
: S"t"&a' %i&aan
tin%aan "!"#a6atan s"&a$a
%i'a#a!an n*"#i !asi"n "##an+ %"n+an
#it"#ia 'asi&5
4 Ka(i a#at"#isti n*"#i -PRST) 4 M"n+"ta'i a#at"#isti n*"#i !asi"n nt
$"n+i%"ntifiasi %a&a$ !"$"#ian int"#7"nsi
*an+ t"!at
4 Panta TT; 4 M"n+i%"ntifiasi "a%aan $$ !asi"n
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
17/37
TT; %a&a$ atas n#$a&
1 TD 5 ,040/110410$$H+
2 Na%i 5 ,04100/$"nit
3 S' 5 3,:43=:<
RR 5 1,42 /$"nitPasi"n $"n+ataan n*"#i
"##an+Sa&a n*"#i "##an+
Pasi"n ta$!a #i&"s"s!#"si 6a(a' ti%a t"+an+.
Knt#asi t"#s ai Pa*%a#a &"$"
Ti%a a%a "n%n+an ASI.
4 Ka(i nt#asi t"#s !#s"s
in7&si t"#i.
4 M"n+i%"ntifiasi !"n*i$!an+an %an "$a(an
"#%asa#an in7&si t"#i.
4
4 An(#an !asi"n nt $"$asa'i !"#in"$ %"n+an ai# 'an+at
s""&$ "#"$i'.
103
4 M"n+#an+i "t"+an+an !a%a &a !"#in"$.
4 An(#an %an &at i' !asi"n a#a$"#a6at !a*%a#a s"a#a t"#at#.
10,
4 M"&ati' i $"n+#an+i "n%n+an ASI %an$"$!"#&ana# !"n+"&a#an ASI.
4 ?"&asan !a%a i t"tan+ t"ni
$"#a6at &a !"#in"$
10
4 M"n"+a' inf"si %an nt#& n*"#i !a%a &a
!"#in"$.
4
4 A(a#an &i"n t"ni #"&asasi %an%ist#asi -t"ni na!as !an(an+ %an
%a&a$ $"n+a&i'an !"#'atian).
112
4 M"n+#an+i int"nsitas n*"#i !a%a !asi"n
4 K&a#asi %"n+an %t"# t"ntan+ !"$"#ian ana&+"si
11:
4 M"#!aan sa&a' sat $ana+"$"nt n*"#i nt !asi"n
11,
R
11=
11
S"
Ti%a a%a tan%a inf"si
-a&# ## %&# t$#fn+si&a"sa )
La "!isit$i "#in+
%an "#si'TT; %a&a$ atas n#$a&
a. TD 5 ,040/110410$$H+
. Na%i 5 ,04100
/$"nit. S' 5 3,:43=:<
%. RR 5 1,42 /$"nit
4 Panta TT; %an tan%a4tan%a inf"si
120
4 M"n+"ta'i "a%aan $$ !asi"n %an a%an*a
tan%a4tan%a inf"si
121
4 Ka(i &a !"#in"$/"!isit$* a(i"a%aan (a'itan.
4 M"n+i%"ntifiasi !"n*i$!an+an %an "$a(ans"sai int"#7"nsi *an+ %i&aan.
12
4 An(#an !asi"n $"$as' 7&7a
s"tia! 'ais "#"$i' %"n+an a#a*an+ "na#
4 K"a%aan &a !"#in"$ "#%"atan %"n+an
%a"#a' asa' $"n+aiatan ""n%"#na+n &ant s"&a& t# %an $%a' t"#"na inf"si.
12=
4 P"#ta'anan t"ni s"!ti as"!ti
%a&a$ $"#a6at !asi"n -$"#a6at
&a !"#in"$ $"#a6at !a*%a#a$"#a6at a*i).
4 M"n"+a' inf"si s"a#a %ini %an $"n"+a'
nta$inasi si&an+ t"#'a%a! inf"si.
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
18/37
11
130
R
131
132
S"
I %a!at $"#a6at a*i
s"a#a $an%i#i-$"$an%ian $"n*si).
K"&a#+a it "#!"#an
atif %a&a$ !"#a6atan i%an a*i
I $a$! $"&aan%an sa%a# aan !"ntin+n*a
!"#6atan %an ""#si'an
%i#i
4 9"#i "s"$!atan i nt
$"&aan !"#a6atan a*i s"a#a
$an%i#i.133
4 M"nin+atan "$an%i#ian i %a&a$ !"#a6atan
a*i.
4 Liatan sa$i %a&a$ !"#a6atan
a*i.
4 K"t"#&iatan a!a/sa$i %a&a$ !"#a6atan a*i
aan $"$ant $"nin+atan "t"#iatan ati'
i %"n+an a*i.4
4 M"$"#ian KIE ""#si'an %i#i
a#a $"n*si *an+ "na# %an !"#a6atan !a*%a#a !"#a'an4 !"#a'an *an+ t"#(a%i !a%a $asa
nifas !"$"#ian inf#$asi t"ntan+s"na$ nifas
13
4 P"#a6atan !a*%a#a s"a#a t"#at# aan
$"$!"#ta'anan !#%si ASI s"a#a ntin*s"'in++a "t'an a*i aan ASI t"#!i.
4 Mti7asi i nt $"nin+atan
inta" ai#an %an %i"t TKTP.
11
4 M"nin+atan !#%si ASI.
4 Laan #a6at +an+ s"s"+"#a$n+in i&a ti%a t"#%a!at
$!&iasi !a%a i ata a*i.
1
4 M"nin+atan 'n+an i %an a*i s"%ini$n+in.
1#?
1#6
1#"
1#8
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
19/37
1#@ DA$TAR PUSTAKA
1?0
1?1 9a 200. Buku Ajar Keperawatan Maternitas, E%isi . ?aa#ta5 EG<
1?2 D"n+"s E. Ma#i&*n. 2001. Rencana Perawatan Maternal/Bayi E%isi 2. ?aa#ta5 EG<
1:3 Ha%i(n
1:
1::
1:,
1:=
1:
1:
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
20/37
1,0 ASUHAN KEPERAWATAN PADA N*.U
1,1 DENGAN POST PARTUS SPONTAN 9ELAKANG KEPALA
HARI I
1,2 DI RUANG 9AKUNG RSUD NEGARA
1,3 TANGGAL 10 s/% 11 SEPTEM9ER 2013
1,
I. PENGKA=IAN
A. IDENTITAS PASIEN PENANGGUNG/SUAMI
1,: Na$a 5 N* U Na$a
5 PS
1,, U$# 5 30 ta'n
U$# 5 30 ta'n1,= P"n%i%ian 5 SMA
P"n%i%ian 5 SMA
1, P""#(aan 5 IRT
P""#(aan 5 S6asta
1, Stas P"#a6inan 5 s%a' $"nia' A&a$at
5 M"&a*a
1=0 A+a$a 5 Is&a$
1=1 A&a$at 5 M"&a*a
1=2 N. ,y,* P&)s,-+',' S&,),'(
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
21/37
10 Pasi"n $"#!aan #(an %a#i !#at" &ini 9i%an %i Pan+n+ Tana'
%"n+an G1P0000 UK 3: $in++ "tan !"a' %ini. Pasi"n $"n+"&' "&a# ai#an
"nin+ !"# 7a+ina$ tan++a& 0 S"!t"$"# 2013 !& 23.00. N*"#i !"#t a+ian a6a'
-4) #i6a*at t#a$a -4) +"#a (anin -). S"sa$!ain*a %i #$a' sait !asi"n %isa#anan
nt $"n+"%an nt#asi !"#t -) !& 0:.00. i&a a*i "&$ &a'i# %a&a$ "$!at (a$
$aa aan %i&aan S
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
22/37
13
1
3 Ri6a*at "'a$i&an !"#sa&inan nifas *an+ &a& 5
18?
1=
K"'a$i&an
1 P"#sa&
inan
1 K$!&
iasi nifas
10
Ana
1P"n*ait
1,1=
1200
2020:
20, 20= 2020n#$a&
210%
t"
#
211 212 213 21 21: 21
21
Ri6a*at K"&a#+a 9"#"nana 5
1) As"!t# K9 5 ti%a $"n++naan
2) R"nana K9 5 K9 snti 3 &an
220
9. POLA $UNGSIONAL KESEHATAN
221 1. P&&-+,),,' d,' &)s&s+ *&),d, &s&,*,'
222 Pasi"n %an "&a#+a san+at !"%&i %"n+an "s"'atan i %an (anin s"&a$a
"'a$i&an. I $"n+ataan s"&a& $"$"#isaan an%n+an " i%an. I $"n+ataan%iataan s"'at i&a !"#tn*a ti%a t"#asa n*"#i.
223 2. N*)+s+/&*,;4-+
22 I $"n+ataan nafs $aan ai. I $aan 3 s"'a#i 'ais 1 !#si. Pantan+an
$aan ti%a a%a. Gan++an $"n"&an -4). Di"t nasi
22: I $"n+ataan $in$ ,4 +"&as ai# !ti'/ 'a#i J1:00
226 3. P4-, E-++',s+
22= I 9A9 1 s"'a#i nsist"nsi &"$" 6a#na nin+ "&atan n*"#i
saat 9A9 -4) %a#a' %a&a$ f"s"s -4).
22 I 9AK 34 %a&a$ s"'a#i 6a#na nin+ n*"#i saat 9AK -4) %a#a'
%a&a$ #in" -4).
22@ #. P4-, ,*++*,s d,' -,*+,'
230 K"$a$
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
23/37
!an
!"#a6ata
n %i#i
23, Maan/
Min$
23= 23 23 20
22 Man%i 23 2 2: 2, 2=
2 Ti&"tin+ 2 2:0 2:1 2:2 2:3
2: 9"#!aai
an
2:: 2:, 2:= 2: 2:
2,0 Mi&isa
si %i
t"$!at
ti%#
2,1 2,2 2,3 2, 2,:
2,, 9"#!in%
a'
2,= 2, 2, 2=0 2=1
2=2 A$&as
i ROM
2=3 2= 2=: 2=, 2==
2= 05 $an%i#i 15 a&at 9ant 25 %iant #an+ &ain 35 %iant #an+
&ain %an a&at5 t"#+antn+ tta&.
2"@ ?. P4-, *+d) d,' +s*+),,*
20 I $"n+ataan $"n+a&a$i +an++an !&a ti%# a#"na !a%a $a&a$ 'a#i a*i
s"#in+ $"nan+is
281 6. P4-, &)5&*,- 4('+*+
22 I "#$niasi %"n+an a'asa In%n"sia %an 9a'asa 9a&i. ?a6aan
s"sai %"n+an !"#tan*aan. Pasi"n $"n+ataan n*"#i !a%a !"#t a+ian a6a' sa&a : n*"#i
%i#asaan ta$a' "#at i&a "#(a&an n*"#i %i#asaan t"#s $"n"#s. Pasi"n (+a $"n+"&'
n*"#i !a%a &a (a'itan %an !a%a !ttin+ ss.
283 ". P4-, &)s&s+ d+)+
2 Pasi"n $"n+ataan san+at a'a+ia %an "#s*# %a!at $"&a'i#an a*i
%"n+an s"&a$at %an s"a#a n#$a&. Pasi"n $"n+ataan ini $"#!aan ana !"#a$a !asi"n
ti%a ta' a#a $"#a6at a*i *an+ "na#.
28? 8. P4-, s&s,- d,' )&)4ds+
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
24/37
2, Pasi"n "#("nis "&a$in !"#"$!an s%a' $"nia'. Saat ini s%a' $"&a'i#an
ana !"#"$!an. M"n*si &"6at ASI -)
28" @. P4-, &),'7;'(,'
2 Hn+an i %"n+an sa$i %an "&a#+a &ainn*a san+at ai. I ti%a $"$i&ii
$s' %"n+an #an+ &ain.
28@ 10. P4-, ,',&&' 4+'( s*)&ss
20 I $"n+ataan i&a $"$i&ii $asa&a' aan $"n%issiann*a %"n+an sa$i.
2@1 11. S+s*& '+-,+ d,' &y,+','
22 I "#a+a$a Hin% i #a(in s"$a'*an+ %i #$a' %an #$a' sait.
23
D. PEMERIKSAAN $ISIK
,. K&,d,,' 1) G
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
25/37
303 P"#si 5 ti%a %ia(i
30 As&tasi 5 S1S2 #"+&"# $$# -4)
:) A%$"n 5
30: Ins!"si5
a) Lin"a 5 ni+#a St#ia" 5 a&ian
) La S< 5 ti%a a%a
30, Pa&!asi5
a) T8U 5 2 (a#i %ia6a' !sat
) Knt#asi 5 -)
) Diastasis #"ts a%$inis 5 ti%a a%a
30= As&tasi 5 9isin+ ss 5 -)
30 P"#si 5 sa#a ti$!ani
30
,) G"n"ta&ia 5a) K""#si'an 5 ti%a %ia(i
) L'"a 5 -) Ka#at"#isti 5 ##a
=) P"#in"$ %an ans 5a) P"#in"$ 5REEDA t'
) H"$#i% 5 ti%a a%a
) Et#"$itas
a) Atas 5
310 O"%"$a 5 -4)/-4)
311 ;a#is"s 5 -4)/-4)
312
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
26/37
323
R
32
32:
10
32,
32=H
3212
32+/
33012
331
H
332
3
333
33
3,
33:
PL
33,
1,
33=
10
33
1
33@
$. DIAGNOSA MEDIS
3#0 POST PARTUS SPONTAN HARI I
3#1
G. PENGOBATAN
32 A$!ii&in :00 $+ PO
33 Asa$ M"f"na$at 3 :00 $+ PO
3 M"ti& E#+$"t#i 3 112: $+ PO
3: S8 2 200 $+ PO
3,
II. ANALISA DATA
3#8 D
ATA
3#@
ETI
3?0
MAS
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
27/37
3:1
3:2
3:3
3:
3::
3:,
3:=
3:
3:
3,0
3,1
3,2
3,3
3,
3,:
3,,
3,=
3,
3,3=0
3=1
3=2
3=3
DS5
1 Pasi"n $"n+ataan n*"#i
!a%a !"#t a+ian
a6a' !a%a &a
(a'itan %an !a%a
!ttin+ ss
2 Pasi"n $"&a!#an sa&a
n*"#i :
3 Pasi"n $"&a!#an n*"#i
%i!"#"#at %"n+an
"#(a&an
3=
DO5
1 Pasi"n ta$!a $"#in+is
"saitan
2 Knt#asi t"#s ai
3 Ta$!a !a*%a#a a+a
$"n"+an+ TD5 110/=0 $$H+
: HR5 /$"nit
, RR5 1 /$"nit
3=:
3=,
DS5
1 I $"n+ataan saat ini
"&a'i#an ana !"#ta$a
2 I $"n+ataan !ttin+
ssn*a t"#asa sait
a#"na &""t
3=
3=
30
31
32
33
3
3:
3,
3=
3
3
30
31
32
33
3
3:
3,
3=
3
3
2
N*"#i
2
P"#sa&inan
n*"#i at
&a !a%a
!"#in"$
t"#!tsn*a
ntinitas (a#in+an
"!isit$i
t#a$a (a&an&a'i#
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
28/37
3 Pasi"n $"n+ataan ti%a
ta' a#a $"#a6at a*i
*an+ "na#
3==
DO5
1 Ta$!a t"ni $"n*si
#an+ t"!at
2 I ti%a $"n+"ta'i a#a
$"#a6at %an
$"$an%ian a*i
00
01
02
03
0
0:
0,
0=0
0
10
11
12
13
1
1:
1,
1=
1
1
20
21
22
23
#isi +an++an
!#s"s !a#"ntin+
!"#sa&inan
ana !"#ta$a
#an+
!"n+ata'an
t"ntan+
!"#a6atan a*i
#isi +an++an
!#s"s !a#"ntin+
"&a'i#an a*i
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
29/37
2
2:
2,
2=
30
#31 D+,('4s, K&&),>,*,' B&)d,s,),' P)+4)+*,s:
1 N*"#i at "#'n+an %"n+an a+"n "%"#a i&+is -!"#sa&inan)
2 Risi +an++an !#s"s !a#"ntin+ "#'n+an %"n+an #an+n*a !"n+"ta'an t"ntan+ a#a
$"#a6at a*i
32
III. REN9ANA KEPERAWATAN
#3# #3? REN9ANA KEPERAWATAN
#38
T
#3@
I
##0
R
1
1.
2:20 S"t"&a'
%i&aan tin%aan
"!"#a6atan s"&a$a22 (a$ %i'a#a!an
n*"#i !asi"n
t"#nt#& %"n+an#it"#ia 'asi&5
a. TD 5 ,04
0/110410
1 Ka(i a#at"#isti
n*"#i -PRST)
:3
:3:
:3,
:3=
1 M"n+"ta'i
a#at"#isti n*"#i
!asi"n nt $"n+i%"ntifiasi
%a&a$ !"$"#ian
int"#7"nsi *an+t"!at
:,
2 M"n+i%"ntifiasi
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
30/37
,=0
=1
=2
=3=
=:
=,==
=
=0
3
:,
=
0
$$H+
. Na%i 5 ,04100 /$"nit
. S' 5 3,:4
3=:<
%. RR 5 1,42/$"nit
". Pasi"n$"n+ataan n*"#i
"##an+
Sa&a n*"#i
043+. Es!#"si
6a(a' ta$!a
#i&"s'. Knt#asi
t"#s ai Pa*%a#a&"$"
Ti%a a%a
"n%n+an ASI.:21
:22
:23
:2
:2:
:2,
:2=
:2
:2
:30
:31
:32
:33
:3
:3
2 Panta TT; :0
:1
3 Ka(i nt#asi t"#s
!#s"s in7&sit"#i
:2
:3
An(#an !asi"n nt $"$asa'i
!"#in"$ %"n+an
ai# 'an+ats""&$
"#"$i'.
: ?"&asan !a%a i
t"tan+ t"ni $"#a6at &a
!"#in"$
, A(a#an &i"n t"ni #"&asasi %an
%ist#asi -t"ni
na!as !an(an+%an %a&a$
$"n+a&i'an
!"#'atian).
= K&a#asi %"n+an%t"# t"ntan+
!"$"#ian
ana&+"si:
::
"a%aan $$
!asi"n3 M"n+i%"ntifiasi
!"n*i$!an+an
%an "$a(an
"#%asa#anin7&si t"#i.
M"n+#an+i"t"+an+an !a%a
&a !"#in"$.
:=
::
: M"n"+a' inf"si %an
nt#& n*"#i !a%a&a !"#in"$.
, M"n+#an+i int"nsitasn*"#i !a%a !asi"n::0
::1
::2
::3
::
= M"#!aan sa&a' sat
$ana+"$"nt
n*"#i nt !asi"n
:::
::,
::=
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
31/37
1
23
:
,=
:00
:01
:02:03
:0
:0::0,
:0=:0:0
:10
:11:12
:13
:1
:1::1,
:1=
:1:1
1
:: :: :,0S
2 I %a!at $"#a6at
a*i s"a#a$an%i#i
-$"$an%ian
$"n*si)3 K"&a#+a it
"#!"#an atif
%a&a$ !"#a6atan i
%an a*i
:,1 I $a$!$"&aan %an sa%a#
aan !"ntin+n*a
!"#6atan %an
1 9"#i "s"$!atan int $"&aan
!"#a6atan s"a#a
$an%i#i
2 Liatan sa$i %a&a$ !"#a6atan a*i
:,2
:,3
:,
:,:
:,,:,=
3 M"$"#ian KIE
""#si'an %i#i
1 M"nin+atan"$an%i#ian i
%a&a$ !"#a6atan
a*i
:,
2 K"t"#&iatan
a!a/sa$i%a&a$ !"#a6atan
a*i aan
$"$ant$"nin+atan
"t"#iatan atin
a!a %"n+an a*i
3 P"#a6atan !a*%a#a
s"a#a t"#at#
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
32/37
""#si'an %i#i a#a $"n*si
*an+ "na# %an !"#a6atan
!a*%a#a
!"#a'an4
!"#a'an *an+t"#(a%i !a%a $asa
nifas !"$"#ianinf#$asi t"ntan+
s"na$ nifas.
Mti7asi i nt
$"nin+ataninta" ai#an %an
%i"t TKTP
Laan #a6at+an+ s"s"+"#a
$n+in i&ati%a t"#%a!at$!&iasi !a%a
i ata a*i
aan
$"$!"#ta'anan !#%si ASI
s"a#a ntin*
s"'in++a
"t'an a*iaan ASI
t"#!i.:,
:=0
M"nin+atan
!#%si ASI:=1
:=2
:=3 M"nin+atan
'n+an i %an a*i s"%ini$n+in.
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
33/37
?"#
?"? D. IMPLEMENTASI
?"6?"@ IM
PL
E
M
ENTA
SI
?80
E<
?81
RE
?82
?83
: S"&asa 10
S"!t"$"#
2013
:: 0.00:,
:=
:: 0.00
:0:1
:2 10.00
:3
:::
,=:1
,=,
,==
,=,=
,0
,1
,21
,3,
,:
,,
2,=
M"&aan !"n+a(ian n*"#is"a#a $!#"'"nsif
=,
=,
==0==1
==2
M"n+a(a#an t"ni $ana("$"n
n*"#i na!as %a&a$ %an%ist#asi
==3M"$"#ian "s"$!atan !a%a
i nt $"&aan
!"#a6atan a*i s"a#a
$an%i#i==
0, S 5 !asi"n$"n+ataan n*"#i %i
!"#t a6a' %i"as
(a'itan %an %i !tin+
ss &i"n$"&a!#an sa&a
n*"#i :
0=
0 S 5 !asi"n$"n*ataan
$"$a'a$i0
10
11O 5 !asi"n ta$!a
$"&aan !"#a6atan !a%a a*i
,0
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
34/37
:,
:=: 11.00
:
,00
,01 12.00,02
,03,0
,0:
,0, 13.00
,0=,0
,0 1:.00
,10,11
,12,13,1
,1: 1,.00
,1,,1=
,1
,1
,20 1=.00,21
,22
,23,2
,2: 1=.00
,2,,2=
,2
,2
,30 1.00,31
,32
,33
,3 Ra11 S"!t"$"#
2013
,3: 0.00,3,
,3=
,
,,0
,1
2
,2,3
,2
,:
,,
,=,
,
1=00
=01=02=03
1
=0=0:
=0,
=0=
=01
=0
=10=11
=12
=131
=1
=1:
=1,=1=
=1
1=1
=20
=21=22
=23
2=2
=2:
M"&iatan sa$i %a&a$
!"#a6atan a*i==:
M"$"#ian KIE ""#si'an
%i#i a#a $"n*si *an+
"na# a#a !"#a6atan !a*%a#a
==,M"n+# TT;
===
==
==10 M"n+a(i nt#asi t"#s tin++i
T8U !a*%a#a
=0=1
1112 M"$"#ian at #a& a$!ii&in:00 $+ asa$ $"f"na$at :00
$+ $"ti& "#+$"t#i 012: $+
=213 M"n+an(#an i nt
$"$asa'i !"#in"$ %"n+an
ai# 'an+at s""&$ "#"$i'
=3=
1 M"n("&asan !a%a i t"ntan+
t"ni $"#a6at !"#in"$=:
=,
==1: M"n+an(#an i nt
$"nin+atan inta" ai#an
%an TKTP
=1, M"$"#ian at #a& a$!ii&in
:00 $+ asa$ $"f"na$at :00
$+ $"ti& "#+$"t#i 012:$+ S8 200 $+.
=
1= M"n+an(#an i nt$"nin+atan inta" ai#an
%an TKTP
=0=1
1 M"n+an(#an i nt
12
131 O 5 sa$i ta$!a
it %a&a$ !"#a6atan
a*i
1:1, S 5 !asi"n
$"n*ataan$"$a'a$i
1=
1
120 O 5 TD5 110/=0
$$H+
21 N 5 0/$"nit
22 S 5 3,:° <
232 O 5 t"#%a!at
nt#asi T8U 3 (a#i
%ia6a' !sat !a*%a#a $"n"+an+.
2:
2, O 5 at $as
ti%a a%a #"asi a&"#+iti%a a%a $a& %an
$nta'.
2=2
2 S 5 !asi"n
$"n+ataan$"$a'a$i a#a
$"$"#si'an
!"#in"$
3031 S 5 i $"n+ataan
$"$a'a$i t"ntan+
t"ni !"#a6atan &a
!"#in"$32
33 S 5 I$"n+ataan
$"$a'a$i
33:
3, O 5 at $as
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
35/37
,3 0.00
,3,0
,1
,2
,3 12.00,
,:,,
,=
, 1.00
,,:0
,:1 1:.00
,:2,:3
,:,:: 1,.00,:,
,:=
,:,:
,,0
,,1
,,2 1=.00,,3
,,
,,:,,,
,,= 1.00
,,,,
,=0
,=1
,=220.00
,=3
,=
=2,
=2=1
=2
=2
=30=31
=32=33
2
=3
=3:=3,
=3=
=31
=3=0=1
=2
=31
=
=:
=,1
==
==
=:0
1=:1
=:2
=:3
=:=::
=:,
=:=2
=:
=:=,0
=,1
=,21
=,3
$"$asa'i !"#in"$ %"n+an
ai# 'an+at s""&$ "#"$i'=2
=3
1 M"&aan !"n+a(ian n*"#i
s"a#a $!#"'"nsif =
20 M"n+an(#an !asi"n $"&aan$ana("$"n n*"#i %ist#asi
=:
21 M"n+a(i nt#asi t"#s tin++i
T8U %an !a*%a#a=,
==
==
0022 M"$"#ian "s"$!atan !a%ai $"&aan !"#a6atan
a*i s"a#a $an%i#i
0123 M"n+# TT;
02
03
00:
2 M"n+an(#an !asi"n nt
$"n(a+a ""#si'an %i#i a#a$"n*si *an+ "na# a#a
!"#a6atan !a*%a#a
ti%a a%a #"asi a&"#+i
ti%a a%a $a& $nta'3=
3
3
0 S 5 i $"n+ataan$"$a'a$i t"ntan+
nt#isi *an+ 'a#s %ins$si.
1
2 S 5 i $"n+ataan
$"$a'a$i t"ntan+a#a $"$"#si'an
!"#in"$
3 S 5 !asi"n
$"n+ataan n*"#i "#sa&a 3:
, S 5 !asi"n
$"n+ataan n*"#it"#nt#&
=
O 5 t"#%a!atnt#asi T8U 5 3 (a#i
%ia6a' !sat
!a*%a#a5 t"#%a!at !"n+"&a#an
&st#$s ti%a a%a
"n%n+an ASI.:0
:1 O 5 i ta$!a
$"$"#ian
!"#a6atan !a%a a*i:2
:3
:O 5
:: N 5 0/$"nit:, RR 5 1/$"nit
:= S 5 3,: °<
:
:
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
36/37
=,
=,:=,,
=,=
2
S 5
861862 E. E
8/18/2019 ASUHAN KEPERAWATAN partus spontan.docx
37/37
!a*%a#a
1=Sa$i ta$!a it $"$ant !"#a6atan a*i
1I ta$!a $a$! $"n(a+a ""#si'an %i#i
1 A 5 T(an t"#a!ai $asa&a' t"#atasi
20 P 5 P"#ta'anan n%isi !asi"n !asi"n #"nana
&"' !&an+.
22
23
2
2:
2,
2=
2
2
30
31
32
33
3
3: