A. IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................
C. RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
Menarche : umur.................... Siklus : teratur ( ) tidak ( )
Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
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b. Riwayat kehamilan, persalinan, nifas :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Usia Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan
c. Genogram :
D. RIWAYAT PERSALINAN DAN POST PARTUM SEKARANG
a. Keluhan kontraksi
b. Pengeluaran pervaginan
c. Kala persalinan
Kala 1
Kala 2
Kala 3
Kala 4
DATA BAYI
Bayi lahir tanggal/ jam..................................
Jenis kelamin................................................
Nilai APGAR..................................................
BB/PB/Lingkar kepala bayi.................gram..................cm................cm
Kelainan Kepala
Suhu...........................c
Anus: berlubang/ tertutup
Perawatan tali pusat.................................
Perawatan mata..........................................
F. RIWAYAT KESEHATAN :
a. Penyakit yang pernah dialami ibu : ........................................................................
b. Pengobatan yang didapat : ......................................................................................
c. Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................
G. RIWAYAT LINGKUNGAN :
- Kebersihan :
...........................................................................................................…………….......
- Bahaya :
…………......................................................................................................................
- Lainnya sebutkan :
.................................................................................…………………….....................
H. ASPEK PSIKOSOSIAL :
1. Persepsi ibu tentang persalinan saat ini: ................................................................
2. Harapan yang ibu inginkan : ..................................................................................
3. Ibu tinggal dengan siapa : .......................................................................................
4. Siapakah orang yang terpenting bagi ibu................................................................
5. Sikap anggota keluarga terhadap keadaan saat ini .................................................
6. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
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I. KEBUTUHAN DASAR KHUSUS (DI RUMAH DAN DI RS) :
1. Pola Nutrisi
a. Frekwensi makan : .............................. x sehari
b. Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
c. Jenis makanan rumah : ................................................................................….
d. Makanan yang tidak disukai/ alergi/ pantangan : .............................................
2. Pola eliminasi :
a. B A K
a. Frekwensi : ....................kali
b. Warna :
.......................……………………………………………….
c. Keluhan saat BAK : .................................................………......................
b. B A B
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
a. Konsistensi : .............……………………………………………….........
b. Keluhan ....................................................................………....
3. Pola personal hygiene
a. Mandi
a. Frekwensi : ...................................x /hari
b. Sabun : ( ) ya, ( ) tidak
b. Oral hygiene
a. Frekwensi : ...................................x /hari
b. Waktu : ( ) ya, ( ) tidak
c. Cuci rambut
a. Frekwensi : ...................................x /hari
b. Shampo : ( ) ya, ( ) tidak
4. Pola istirahat dan tidur
a. Lama tidur : ............................jam/hari
b. Kebiasaan sebelum tidur : ................................................................................
c. Keluhan : ..........................................................................................................
5. Pola aktifitas dan latihan
a. Kegiatan dalam pekerjaan : ..............................................................................
b. Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
c. Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
d. Kegiatan waktu luang : .....................................................................................
e. Keluhan dalam beraktifitas : ............................................................................
6. Pola kebiasaan yang mempengaruhi kesehatan
a. Merokok :
..............................................................................................
b. Minuman keras :
..............................................................................................
c. Ketergantungan obat :
..............................................................................................
J. PEMERIKSAAN FISIK
a. Keadaan umum : ......................................Kesadaran : .........................
b. Tekanan darah : ......................................Nadi : .............x/menit
c. Respirasi : .....................................Suhu : .......…........C
d. Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :
Kepala : Bentuk ..........................................................
Keluhan :........................................................
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Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Lainnya sebutkan : .................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
Gigi geligi : .....................................................................................................
Kesulitan menelan : ................................................................................................
Lainnya sebutkan : .................................................................................................
Dada dan Axilla
Mammae : membesar ( ) ya ( ) tidak
Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Menggunakan otot-otot bantu pernafasan : ............................................................
Lainnya sebutkan : .................................................................................................
Sirkulasi jantung
Kecepatan denyut apical : ...............................x/menit
Irama : ...............................................................................................
Kelainan bunyi jantung : ........................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Lainnya sebutkan : ..............................................................................................
Abdomen
Tinggi fundus uterus: cm Kontraksi: ya/ tidak
Bising usus
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Ekstrimitas (integumen/muskuloskeletal)
Turgor kulit :
Warna kulit :
Edema :
Kontraktur pada persendian ekstrimitas :
Tanda Homan : +/-
Kesulitan dalam pergerakan :
Lainnya sebutkan :
L. DATA PENUNJANG
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
....................................................................................................................................
....................................................................................................................................
.....................................................................................................
M. DATA TAMBAHAN
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................
Surabaya, ........................................
Pemeriksa
(..................................................)