Pengkajian Post Natal

ASUHAN KEPERAWATAN PADA Ny

DENGAN ..
Di RUANG
TANGGAL .

A. PENGKAJIAN
I.

IDENTITAS PASIEN
Nama

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

Umur

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

Pendidikan

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

Pekerjaan

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

Status perkawinan : .......................................

Agama

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

Suku

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

Alamat

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

No. CM

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

Tanggal MRS

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

Tanggal pengkajian: ........................................

Sumber Informasi : ........................................
Diagnosa masuk

II.

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

PENANGGUNG/ SUAMI
Nama

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

Umur

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

Pendidikan

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

Pekerjaan

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

Alamat

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

Hubungan dengan pasien : ........................................

III. RIWAYAT PENYAKIT

Keluhan utama (saat MRS dan sekarang)

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Riwayat Penyakit Sekarang

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IV. RIWAYAT OBSTETRI DAN GINEKOLOGI

1.

2.

Riwayat Menstruasi :
Menarche

: umur .................

Siklus

: teratur ( )

Banyaknya

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

Lamanya

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

Keluhan

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

Riwayat Pernikahan :
Menikah : ................. kali

3.

Lama : ............... tahun

Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke
No

tidak ( )

Tahun

Kehamilan
Umur
Kehamilan

Penyulit

Persalinan
Jenis

Penolong

Komplikasi Nifas
Penyulit

Laserasi

Infeksi

Perdarahan

Anak
JK

BB

Pj

4.

5.

Riwayat Keluarga Berencana :

Akseptor KB

: jenis .....................

Masalah

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

Lama : .........................

Riwayat Penyakit Klien dan Keluarga

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V.

POLA FUNGSIONAL KESEHATAN

a.

Pemeliharaan dan persepsi terhadap kesehatan

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b.

Nutrisi/ metabolic
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c.

Pola eliminasi
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d.

Pola aktivitas dan latihan

Kemampuan perawatan diri

Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total
Keterangan :

e.

Pola tidur dan istirahat

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f.

Pola perseptual
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g.

Pola persepsi diri

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h.

Pola seksual dan reproduksi

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i.

Pola peran-hubungan
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j.

Pola manajemen koping stress

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k.

Sistem nilai dan keyakinan

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V. PEMERIKSAAN FISIK
Keadaan Umum
GCS

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

Tingkat Kesadaran : .......................................................................................

Tanda-tanda vital : TD ............... N ................. RR ................ T................
BB

: ..................... TB ................ LILA : ......................

Head to toe
Kepala

Wajah

Mata

Leher

Dada

Payudara

Inspeksi :
Areola .................

Puting : (menonjol/tidak)

Tanda dimpling/retraksi : ....................................

Palpasi : Pengeluaran ASI ......................
Adanya nodul : ...........................

Jantung dan Paru :

Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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Abdomen :

Inspeksi

: Linea : .................. Striae : ...............

Luka SC : .......................

Auskultasi

: Bising usus : .

Palpasi

TFU

: .

Kontraksi

Diastasis rectus abdominis

: .

Perkusi

.........................................................................................................
Genetalia dan Perineum :

Kebersihan

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

Lokhea

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

Perineum

: REEDA ........................................................................

Karakteristik : .......................................................................................

Anus :
Haemorroid

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

Ekstremitas atas

Ekstremitas bawah

Oedema

Oedema

Varises

Varises

CRT

CRT

Kekuatan otot :

Kekuatan otot :

Tonus

Tonus

VI. DATA PENUNJANG

a.

Data laboratorium yang berhubungan

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b.

Pemeriksaan Radiologi
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VII.

DIAGNOSA MEDIS
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VIII.

PENGOBATAN
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B.

ANALISA DATA
DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN
RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN
NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

Mengetahui,
Pembimbing klinik/CI

Mahasiswa

(...................................)

(.............................................)

NIP.

NIM.
Clinical Teacher/ CT

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