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ASUHAN KEPERAWATAN PADA Ny “ ”DENGAN PERSALINAN NORMAL
DI RUANG TANGGAL 2015 .
I. PENGKAJIAN A. IDENTITAS PASIEN
Penangg ng !a"a#Na$a % Na$a %U$ & % U$ & %Pen'('()an % Pen'('()an %Pe)e&*aan % !en(+ )e,a$(n %S-a- + Pe&)a"(nan % Pe)e&*aan %
Aga$a % A,a$a- %S ) % S-a- + e&)a"(nan %
A,a$a- % Aga$a %N/ M %Tangga, MRS %Tangga, Peng)a*(an %S $#e& (n /&$a+( %
. DATA KESEHATAN
a. Ke, 3an U-a$a %
#. Ke, 3an +aa- '()a*( %
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C. RIWAYAT OBSTETRI DAN GINEKOLOGI1.R("aya- Men+-& a&+( %
• Mena&43e % $ & .. S(), + % -e&a- & 6 -('a) 6• anya)nya % . La$a %• Ke, 3an % •
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• A)+e -/& K % ... !en(+% La$a%• Ma+a,a3 %
D. RIWAYAT PENYAKIT1. K,(en %
2. Ke, a&ga %
E. POLA KEBUTUHAN SEHARI-HARI1. e&na a+ %
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2. N -&(+( $a)an8$(n $6 %
9. E,($(na+( %
:. Ge&a) a'an %
5. I+-&(&a3a- -(' & %
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=. Ke#e&+(3an D(&( %
>. Ra+a A$an %
10. P/,a K/$ n()a+(8H # ngan Dengan O&ang La(n %
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11. I#a'a3 %
12. P&/' )-(?(-a+ %
19. Re)&ea+( %
1:. Ke# - 3an #e,a*a& %
F.PEMERIKSAAN FISIKKea'aan $ $ %• G S % ..• T(ng)a- )e+a'a&an % .• Tan'a -an'a ?(-a, % TD@ ........$$Hg7 N@........)a,(8$en(-. RR@
.........)a,(8$en(-7 T@....... /
• % )g 7 .T % 4$ 7 LILA % ..
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+),e&a %.........................................................................)/n* ng-(?a %.................................................................%
e$#e+a&an ,($ 3e n/'e %............... .......... ..... ..... ..... ..e$#e+a&an )e,en*a& -(&/(' %..........................................
• -e,(nga %
• Da'aPay 'a&a
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A&e/,a % .. P --(ng % $en/n*/, 8 -('a) 6 Tan'a '($ ,(ng 8 &e-&a)+( % .
Penge, a&an ASI % .. !an- ng % . Pa& % ..
• A#'/$enL(nea % S-&(ae %Pe$#e+a&an +e+ a( UK % .Ge&a)an !an(n % .. K/n-&a)+( % .L )a #e)a+ / e&a+( % ..
a,,/--e$en- % ..Le/ /,' I % Ke a,a 8 #/)/ng 8 )/+/ng TBU% .............Le/ /,' II % Kanan % ngg ng8 #ag(an )e4(,8 #/)/ng 8 )e a,a
K(&( % ngg ng 8 #ag(an )e4(, 8#/)/ng8)e a,aLe/ /,' III % P&e+en-a+( )e a,a 8 #/)/ng8)/+/ngLe/ /,' IC % ag(an $a+ ) PAP )/n?e&gen8'(?e&gen8+e*a*a&6Pen & nan )e a,a % ....... .. en & nan #ag.-e&#a"a3 'engan $e-/'e
,($a *a&( 6K/n-&a)+( % .D!! % .. (+(ng + + ..
• Gene-a,(a 'an e&(ne $ %Ke#e&+(3an %Penge, a&an % . Ka&a)-e&(+-() % ..Ha+(, CT % .He$/&/(' %
• E)+-&e$(-a+ A-a+ %
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G.DATA PENUNJANG• Pe$e&()+aan La#/&a-/&( $ %
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H.DIAGNOSA MEDIS
I. PENGOBATAN
II. ANALISA DATA KALA I
DATA ETIOLOGI MASALAH
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.E ALUASI KALA I
Tg,8!a$ N/ D E?a, a+( Ha+(,
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KALA IIA. DATA FOKUS KALA II
B. ANALISA DATA KALA IIDATA ETIOLOGI MASALAH
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D(agn/+a )e e&a"a-an #e&'a+a&)an &(/&(-a+ %1. ........................................
2.........................................
9.........................................
C. RENCANA KEPERAWATAN KALA IINo Tgl /
j !D" g#o$ R%#& # K%'%( ) * #
T+j+ # I#*%(,%#$" R $"o# l
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Tg,8!a$ N/.D I$ ,e$en-a+( E?a, a+( P&/+e+ Pa&a 8Na$a
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E. E ALUASI KALA II
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Tg,8!a$ N/ D E?a, a+( Ha+(,
KALA III
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2. ....................................... ..
9. ..................................... ....
C. RENCANA KEPERAWATAN KALA IIINo Tgl /
j !D" g#o$ R%#& # K%'%( ) * #
T+j+ # I#*%(,%#$" R $"o# l
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D. IMPLEMENTASI KALA IIITg,8!a$ N/.D I$ ,e$en-a+( E?a, a+( P&/+e+ Pa&a 8Na$a
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