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Format Pengkajian Maternitas - Post Patum

Format Pengkajian Maternitas - Post Patum

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Dipublikasikan oleh Anisa Rooses
LAPORAN KASUS
..................................................................................................................................................................... ..................................................................................................................................................................... ..........................................................................................................................................................
LAPORAN KASUS
..................................................................................................................................................................... ..................................................................................................................................................................... ..........................................................................................................................................................

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LAPORAN KASUS

.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
Tanggal ................................
Oleh :
_________________________
NIM ...............................
PROGRAM STUDI ILMU KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2010/2011
LEMBAR PENGESAHAN
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
Tanggal ................................
Oleh :
_________________________
NIM ...............................
Mengeta!"#
Peng!$" Pen%"%"&an
______________________
S!'a(a)a# ................ 20.....
Peng!$" Laan
______________________
FORMAT PENGKAJIAN POST PARTUM
UNIT KEPERAWATAN MATERNITAS
Tangga* +a,!& - ........................................
R!ang/&e*a, - ........................................
Peng&a$"an tangga* - ........................................
.a+ +a,!& - ........................................
Ka+a' n/. - ........................................
.a+ 0eng&a$"an - ........................................
I. IDENTITAS
Na+a 0a,"en - ..................................
U+!' - ..................................
S!&!/(ang,a - ..................................
Aga+a - ..................................
Pen%"%"&an - ..................................
Pe&e'$aan - ..................................
A*a+at - ..................................
Stat!, 0e'&a1"nan - ..................................
Na+a ,!a+" - ..................................
U+!' - ..................................
S!&!/(ang,a - ..................................
Aga+a - ..................................
Pen%"%"&an - ..................................
Pe&e'$aan - ..................................
A*a+at - ..................................
II. RIWAYAT KEPERAWATAN
1. R!a"a# O$%#e#&
A. R!a"a# Men%#&'a%
Mena'2e - !+!' .........................
Ban)a&n)a - ..................................
HPHT - ..................................
S"&*!, - te'at!' 3 4 t"%a& 3 4
La+an)a - ..................................
Ke*!an - ..................................
B. R!a"a# Keha(lan) Pe&%alnan) N*a% Yang Lal'
Ana& &e Kea+"*an Pe',a*"nan K/+0*"&a," n"5a, Ana&
N/. Ta!n U+!' &ea+"*an Pen)!*"t .en", Pen/*/ng Pen)!*"t La,e'a," In5e&," Pe'%a'aan .en", BB P.
+. Gen,g&a(
D. P,%# Pa&#'( Se-a&ang
R"1a)at 0e',a*"nan ,e&a'ang - ................................................................................................
T"0e 0e',a*"nan - S0/ntan/(ant!an ..............................
La+a 0e',a*"nan-
• Ka*a I -
..................... $a+
• Ka*a II -
..................... $a+
• Ka*a III -
..................... $a+
• Ka*a I6 -
..................... $a+
E. Ren.ana Pe&a!a#an Ba" : 3 4 ,en%"'" 3 4 /'ang t!a 3 4 *a"n7*a"n
Ke,angg!0an %an 0engeta!an %a*a+ +e'a1at (a)" -
• B'ea,t 2a'e- .........................................
• Pe'"nea* 2a'e- .........................................
• N!t'"," - .........................................
• Sena+ n"5a, - .........................................
• KB - .........................................
• Men)!,!" - .........................................
/. R!a"a# Kel'a&ga Be&en.ana
• Me*a&,ana&an KB- 3 4 )a 3 4 t"%a&
• B"*a )a $en", &/nt'a,e0," a0a )ang %"g!na&an -
.........................................
• Se$a& &a0an +engg!na&an &/nt'a,e0," -
.........................................
• Ma,a*a )ang te'$a%" -
................................................................................
0. R!a"a# Ke%eha#an
• Peng/(atan )ang 0e'na %"a*a+" "(! -
....................................................................................
• Peng/(atan )ang %"%a0at -
....................................................................................
• R"1a)at 0en)a&"t &e*!a'ga
3 4 D"a(ete, +e**"t!,
3 4 Pen)a&"t $ant!ng
3 4 H"0e'ten,"
3 4 Pen)a&"t *a"nn)a - ,e(!t&an .........................................
1. R!a"a# Lng-'ngan
• Ke(e',"an - .................................................................................
.................................
• Baa)a - .................................................................................
.................................
• La"nn)a# ,e(!t&an -
..................................................................................................................
8. A%2e- P%-,%,%al
a. Pe',e0," "(! ,ete*a (e',a*"n - ...............................................................
(. A0a&a &ea%aan "n" +en"+(!*&an 0e'!(aan te'a%a0 &e"%!0an ,ea'"7a'"9 .....................
B"*a )a (aga"+ana ....................................................................................................................
2. Ha'a0an )ang "(! "ng"n&an ,ete*a (e',a*"n - ...............................................................
%. I(! t"ngga* %engan ,"a0a - ...............................................................
e. S"a0a /'ang )ang te'0ent"ng (ag" "(! - ...............................................................
5. S"&a0 angg/ta &e*!a'ga te'a%a0 &ea%aan ,aat "n" - ...............................................................
g. Ke,"a0an +enta* !nt!& +en$a%" ,e/'ang "(! - 3 4 )a 3 4 t"%a&
3. Ke$'#'han Da%a& Kh'%'%
A. P,la n'#&%
14 :'e&1en," +a&an - ......................................................................................................
24 Na5,! +a&an - ......................................................................................................
;4 .en", +a&anan '!+a - ......................................................................................................
<4 Ma&anan )ang t"%a& %",!&a"/a*e'g"/0antangan - .................................................................
B. P,la el(na%
14 BAK
• :'e&1en," - ........................... &a*"
• Wa'na - .................................
• Ke*!an - .................................
24 BAB
• :'e&1en," - ...........................
×
/a'"
• Wa'na - .....................................
• Ba! - .....................................
• K/n,",ten," - .....................................
• Ke*!an - .....................................
+. P,la 2e&%,nal h"gene
14 Man%"
• :'e&1en," - .....................................
×
/a'"
• Sa(!n - 3 4 )a 3 4 t"%a&
24 O'a* )g"ene
• :'e&1en," - .....................................
×
/a'"
• Wa&t! - 3 4 0ag" 3 4 ,/'e 3 4 ,ete*a +a&an
;4 =!2" 'a+(!t
• :'e&1en," - .....................................
×
/a'"
• Sa+0// - 3 4 )a 3 4 t"%a&
D. P,la %#&aha# #4'&
14 La+a t"%!' - ................................................................................................
24 Ke("a,aan ,e(e*!+ t"%!' -
................................................................................................
;4 Ke*!an - ................................................................................................
E. P,la a-#*#a% 4an la#han
14 Keg"atan %a*a+ 0e&e'$aan-
................................................................................................
24 Wa&t! (e&e'$a - 3 4 0ag" 3 4 ,/'e 3 4 +a*a+
;4 O*a'aga- 3 4 )a 3 4 t"%a&
.en",n)a - ................................................................
:'e&1en," - ................................................................
<4 Keg"atan 1a&t! *!ang - ................................................................................................
84 Ke*!an %a*a+ a&t"5"ta, -
................................................................................................
F. P,la -e$a%aan "ang (e(2enga&'h -e%eha#an
14 Me'/&/& - ......................................................................................................
24 M"n!+an &e'a, - ......................................................................................................
;4 Kete'gant!ngan /(at -
......................................................................................................
5. Pe(e&-%aan F%-
Kea%aan !+!+ - ..................................
Te&anan %a'a - ..................................
Re,0"'a," - ..................................
Be'at (a%an - ............................. &g
Ke,a%a'an - ..................................
Na%" - .................... ×
/+en"t
S!! - ............................. >=
T"ngg" (a%an - ..................................
Ke2ala) (a#a) -'2ng) h4'ng 4an #engg,&,-an :
• Ke0a*a -
Bent!& ........................................................................................................................
• Ke*!an ..............................................................................................................................
......
Ma#a :
• Ke*/0a& +ata - ...............................................................................................................
• Ge'a&an +ata - ...............................................................................................................
• K/n$!ngt"?a - ...............................................................................................................
• S&*e'a - ...............................................................................................................
• P!0"* - ...............................................................................................................
• A&/+/%a," - ...............................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
H4'ng :
• Rea&," a*e'g" - ...............................................................................................................
• S"n!, - ...............................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
M'l'# 4an #engg,&,-an :
• G"g" ge*"g" - ...............................................................................................................
• Ke,!*"tan +ene*an-
...............................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
Da4a 4an a6lla :
• Ma++ae - ..................................................................................................................
• A'e/**a +a++ae -
..................................................................................................................
• Pa0"**a +a++ae-
..................................................................................................................
• =/*/,t'!+ - ..................................................................................................................
Pe&na*a%an :
• .a*an na5a, - ...............................................................................................................
• S!a'a na5a, - ...............................................................................................................
• Mengg!na&an /t/t7/t/t (ant!
0e'na5a,an - ..............................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
S&-'la% 7an#'ng :
• Ke2e0atan %en)!t a0"2a* -
........................................................................................ ×/+en"t
• I'a+a - ......................................................................................................
• Ke*a"nan (!n)" $ant!ng -
......................................................................................................
• Sa&"t %a%a - ......................................................................................................
• T"+(!* - ......................................................................................................
• La"nn)a# ,e(!t&an - ......................................................................................................
A$4,(en :
• Menge2"* - ...............................................................................................................
• L"nea @ ,t'"ae - ...............................................................................................................
• L!&a (e&a, /0e'a," -
...............................................................................................................
• T:U - ...............................................................................................................
• K/nt'a&," - ...............................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
Gen#,'&na&" :
• Pe'"ne!+ - ...............................................................................................................
• L/&ea - ...............................................................................................................
• 6e,"&a !'"na'"a - ...............................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
E-%#&e(#a% 8n#eg'(en9('%-'l,%-ele#al:
• T!'g/' &!*"t - ...............................................................................................................
• Wa'na &!*"t - ...............................................................................................................
• K/nt'a&t!' 0a%a 0e',en%"an
e&,t'e+"ta, - ................................................................................
• Ke,!*"tan %a*a+
0e'ge'a&an - ...................................................................................................
• La"nn)a# ,e(!t&an -
...............................................................................................................
III. DATA PENUNJANG
1. La(/'at/'"!+ - .........................................................................................................
............
2. USG - .....................................................................................................................
;. R/ntgen - .....................................................................................................................
<. Te'a0" )ang %"%a0at -
.....................................................................................................................
I;. DATA TAMBAHAN
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
S!'a(a)a# .....................
Pe+e'"&,a
3...............................4
ANALISA DATA
Na+a &*"en - ..............................................
U+!' - ..............................................
R!angan/&a+a' - ..............................................
N/. RM - ..............................................
N/. Data 3S)+0t/+4 Pen)e(a( 3Et"/*/g"4 Ma,a*a 3P'/(*e+4
PRIORITAS MASALAH
Na+a &*"en - ..............................................
U+!' - ..............................................
R!angan/&a+a' - ..............................................
N/. RM - ..............................................
N/. Ma,a*a Ke0e'a1atan
Tangga* Pa'a5
3Na+a Pe'a1at D"te+!&an Te'ata,"
REN+ANA KEPERAWATAN
N/. D"agn/,a Ke0e'a1atan T!$!an Dan K'"te'"a Ha,"* Inte'?en," Ra,"/na*
TINDAKAN KEPERAWATAN DAN +ATATAN PERKEMBANGAN
N/.
Wa&t!
Tg*/$a+
T"n%a&an TT
Wa&t!
Tg*/$a+
=atatan Pe'&e+(angan
3SOAP4
TT

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