ASUHAN KEPERAWATAN POST PARTUM

A. Data Umum Klien

Inisial klien
: ................(.....thn)
Nama Suami : ....................(......thn)
Pekerjaan
: ..........................
Pekerjaan
: ..................................
Pendidikan
: ..........................
Pendidikan : ..............................
Agama
: ..........................
Agama
: ..................................
Suku bangsa
: ..........................
Status perkawinan : .........................
Alamat
: .............................................................................................

B. Riwayat Kehamilan dan Persalinan Yang Lalu

No

Tahun

Jenis
Persalinan

Penolong

1
2
3
4
Pengalaman Menyusui : ya / tidak

JK

Keadaan Bayi

Masalah

bayi

Waktu Lahir

Kehamilan

Berapa lama :

C. Riwayat Kehamilan saat ini

1. Berapa kali periksa kehamilan :.... Dimana...................................
2. Masalah kehamilan : .............
3. Data
Tambahan
: ..........................................................................................................
......................................................................................................................
...........
D. Riwayat Persalinan
1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV,EF)
SC ......................... Tgl/jam :...............
2. Jenis kelamin bayi : L/P, BB/PB :..............gram/..........cm
3. Perdarahan :...........................cc
4. Masalah dalam persalinan .................................................................

E. Riwayat Ginekologi
1. Masalah ginekologi : .....................
...................................................................................................................
2. Riwayat KB : ................
F. Data Umum Kesehatan Saat Ini
1. Status obstetrik : G..... A..... Post Partum hari ke...........
2. Keadaan umum :................. Kesadaran :................
BB/TB :.............Kg..................cm
3. Tanda Vital
Tekanan Darah:.............mmHg
Nadi:.................... x/mnt
Suhu:............... C
Pernapasan : ...............x/mnt
4. Kepala Leher
Kepala
: .............................................................................................
Mata
: .............................................................................................
Hidung
: ............................................................................................
Mulut
: .............................................................................................
Telinga
: ..............................................................................................
Leher
: ..............................................................................................
Masalah Keperawatan : ...............................................................................
5. Dada
Jantung
: .............................................................................................
Paru
: .............................................................................................
Payudara
: .............................................................................................
Puting susu : .............................................................................................
Pengeluaran ASI : .......................................................................................
Masalah Keperawatan : ..............................................................................
6. Abdomen
Involusi Uterus
Fundus Uteri :....................kontraksi : .................Posisi :......................
Fungsi pencernaan : ....................................................................................
Data
Tambahan
: ..........................................................................................................
......................................................................................................................
...........
Masalah Keperawatan : .............................................................................
7. Perineum dan Genital
Vagina : integritas kulit..........Edema..........Memar.........Hematom.........
Perineum : Utuh/episiotomi/ruptur Tanda REEDA
R : Kemerahan : ya/tidak
E : Edema : ya/tidak
E : Ekimosis : ya/tidak
D :Dischargeserum/pus/darah/tidak ada
A : Approximate : baik/tidak
Kebersihan :.............................................................................
Lokia

Jumlah : .................................. Jenis/warna :...............................

Konsistensi : ............................ Bau : .........................................
Hemorrhoid
Derajat :................................... Lokasi : .........................................
Berapa lama : ......................... Nyeri : ya/tidak
Masalah Keperawatan :...............................................................................
8. Ekstremitas
Ekstremitas Atas
: Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah : Edema : ya/tidak
Varises : ya/tidak
Tanda Homan : +/Refleks patela : +/- jika ada : +1/+2/+3
Masalah Keperawatan : ...........
9. Eliminasi
Urin : kebiasaan BAK.............
BAK saat ini......................................Nyeri/tidak
Fekal : kebiasaan BAB................................................................................
BAB saat ini.....................................Konstipasi : ada/tidak
Masalah Keperawatan :................................................................................
10. Istirahat dan Kenyamanan
Pola tidur : kebiasaan tidur : lama.............jam, Frekuensi...........................
Pola tidur saat ini.........................................................................................
Keluhan ketidaknyamanan : ya/tidak, lokasi...............................................
Sifat................................intensitas........................................................
11. Mobilisasi dan Latihan
Tingkat mobilisasi :...........................................................................
Latihan/senam : ................................................................................
Masalah Keperawatan : .....................................................................
12. Nutrisi dan Cairan
Asupan Nutrisi : Nafsu Makan : Baik/Kurang/Tidak Ada
Asupan Cairan : Cukup/Kurang
Data
Tambahan
: ..........................................................................................................
......................................................................................................................
...........
Masalah Keperawatan : ...............................................................................
13. Keadaan Mental
Adaptasi psikologis : ..................................................................................
Penerimaan terhadap bayi :.........................................................................
Masalah Keperawatan : ..............................................................................
14. Kemampuan Menyusui: ..............................................................................
......................................................................................................................
......................................................................................................................
Masalah Keperawatan : ...............................................................................

15. Obat-obatan yang dikonsumsi saat ini

......................................................................................................................
.....................................................................................................................
......................................................................................................................
......................................................................................................................
16. Hasil pemeriksaan penunjang
Laboratorium tgl .................
Pemeriksaan

Hasil

Nilai Normal

Pemeriksaan

Hasil

Nilai Normal

G. Analisa Data
No
.

Data Fokus

Etiologi

Masalah Keperawatan

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H. Diagnosa Keperawatan
No
.

Diagnosa Keperawatan

I. Rencana Asuhan Keperawatan

No

Diagnosa keperawatan

Rencana Tindakan Keperawatan

Tujuan dan Kreteria hasil

Intervensi

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J. Catatan Perkembangan

No

Hari/Tgl
Jam

DX

Implementasi

Evaluasi

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