KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS SAM RATULANGI

FAKULTAS KEDOKTERAN
PROGRAM STUDI ILMU KEPERAWATAN
KAMPUS UNSRAT KOTAK POS No. 333 MANADO 95115SULAWESI UTARA

PENGKAJIAN POST PARTUM

DATA UMUM KLIEN

Inisial klien : .............................................
Usia : .............................................
Status perkawinan : .............................................
Pekerjaan : .............................................
Pendidikan terakhir : .............................................
Inisial Suami : .............................................
Usia : .............................................
Status perkawinan :...........................................
Pekerjaan : .............................................
Pendidikan terakhir : ............................................

Riwayat Kehamilan dan Persalinan Yang Lalu

No. Tahun Tipe Penolong Jenis BB Keadaan bayi Masalah
Persalinan kelamin lahir waktu lahir kehamilan

Pengalaman menyusui : Ya / Tidak Berapa lama :

Riwayat Kehamilan saat ini

1. Berapa kali periksa kehamilan
2. Masalah kehamilan

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 : ............................................................................................................
Riwayat Ginekologi
1. Masalah ginekologi : ............................................................................................................
2. Riwayat KB : ............................................................................................................

DATA UMUM KESEHATAN SAAT INI

Status obstetrik : G...... P...... A...... Bayi Rawat Gabung : Ya / Tidak
Jika tidak, alasan : ............................................................
Keadaan umum : ..................... Kesadaran : ..................... BB/TB : ..................... kg/cm

TTV : TD .................. mmHg

N .................. x/mnt
R .................. x/mnt
S...............oC
Kepala Leher
Kepala : ............................................................................................................
Mata : ............................................................................................................
Hidung : ............................................................................................................
Mulut : ............................................................................................................
Telinga : ............................................................................................................
Leher : ............................................................................................................
Masalah Khusus : ............................................................................................................
Dada
Jantung : ............................................................................................................
Paru : ............................................................................................................
Payudara : ............................................................................................................
Puting susu : ............................................................................................................
Pengeluaran ASI : ............................................................................................................
Masalah Khusus : ............................................................................................................
Abdomen
Involusi Uterus
Fundus Uteri : ........................... Kontraksi : . ........................... Posisi : ...........................
Kandung kemih : ............................................................................................................
Diastasis rektus abdominis : ..................... x ..................... cm
Fungsi pencernaan : ............................................................................................................
Masalah Khusus : ............................................................................................................
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 ......
A : Approximate : Baik / Tidak
Kebersihan : ............................................................................................................
Lokia : Jumlah :
Jenis / warna :
Konsisensi :
Bau :
Hemorrhoid : Derajat : ........................... Berapa lama ...........................
Lokasi : .......................... Nyeri : Ya / Tidak
Masalah khusus : ............................................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Refleks patela : +/- jika ada : +1/+2/+3
Masalah khusus :
Eliminasi
Urin : kebiasaan BAK : ............................................................................................................
Fekal : kebiasaan BAB : ............................................................................................................
Masalah Khusus : ............................................................................................................
Mobilisasi dan Latihan
Tingkat mobilisasi : ............................................................................................................
Latihan/senam : ............................................................................................................
Masalah khusus : ............................................................................................................
Nutrisi dan Cairan
Asupan nutrisi : nafsu makan : baik/kurang/tidak ada
Asupan cairan : cukup/kurang
Masalah khusus : ............................................................................................................
Keadaan Mental
Adaptasi psikologis : ............................................................................................................
 Penerimaan terhadap kehamilan :................................................................................................
Masalah khusus : ............................................................................................................
Kemampuan menyusui : ............................................................................................................
Obat-obatan yang dikonsumsi saat ini : ...............................................................................................
Hasil pemeriksaan penunjang : ............................................................................................................

RANGKUMAN HASIL PENGKAJIAN

Masalah : ............................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
......................................................................................................................................................
Perencanaan Pulang :
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
....................................................................................................................................