FORMAT PENGAJIAN POSTNATAL

KEPERAWATAN MATERNITAS

Nama Mahasiswa : ..............................................................................................

Tempat Praktek : ..............................................................................................
NIM : ..............................................................................................
Tanggal Pengkajian : ..............................................................................................

A. Data Umum
Nama pasien : ..................................................................................
Usia : ..................................................................................
Status perkawinan : ..................................................................................
Pekerjaan : ..................................................................................
Pendidikan : ..................................................................................
Agama : ..................................................................................
Suku bangsa : ..................................................................................
Alamat : ..................................................................................
Nama suami : ..................................................................................
Usia suami : ..................................................................................
Status perkawinan : ..................................................................................
Pekerjaan : ..................................................................................
Pendidikan : ..................................................................................

1. Riwayat kehamilan dan persalinan yang lalu

Keadaan
Tipe Jenis BB Komplikasi
No Tahun Penolong bayi saat
persalinan kelamin lahir nifas
lahir

Pengalaman menyusui : Ya / Tidak Berapa lama :..........................

2. Riwayat kehamilan saat ini

a. Berapa kali periksa hamil : ..........................................................
b. Masalah kehamilan : ..........................................................

3. Riwayat persalinan riwayat ginekologi

a. Jenis persalinan : Spontan (Let.kep/ Let.Su)
Tindakan (forceps/ ekstraksi vakum)
SC a.i (atas indikasi) : ..............................................
Tanggal/Jam : ..........................................................
b. Jenis kelamin bayi : L/P, BB...........gr, PB...........cm, A/S:......
c. Perdarahan : ...........................cc
d. Masalah dalam persalinan : ..................................................................
 4. Riwayat ginekologi
a. Masalah ginekologi : ......................................................................
b. Riwayat KB : ......................................................................

B. Data umum kesehatan saat ini

1. Status obstetri: P.........A.........H......... Bayi rawat gabung : Ya / Tidak
Jika Tidak, alasanya : ...................................................................................
2. Keadaan umum : .................................. Kesadaran : ...................................
BB....................kg TB......................Cm
Tanda vital : TD : .................. mmHg Nadi : ................... x/menit
S : ..................oC RR : ................... x/menit
3. Kepala leher
a. Kepala : ..................................................................................
b. Mata : ..................................................................................
c. Hidung : ..................................................................................
d. Mulut : ..................................................................................
e. Telinga : ..................................................................................
f. Leher : ..................................................................................
g. Masalah khusus : ..................................................................................
4. Dada
a. Jantung : ..................................................................................
b. Paru : ..................................................................................
c. Payudara : ..................................................................................
d. Putting susu : ..................................................................................
e. Pengeluaran ASI : ..................................................................................
f. Masalah khusus : ..................................................................................
5. Abdomen
a. Involusi uterus : ..................................................................
b. Kandung kemih : ..................................................................
c. Diastasis rektus abdominis : ..................................................................
d. Fungsi prncernaan : ..................................................................
e. Masalah khusus : ..................................................................
6. Perineum dan genital
a. Vagina : Intregitas : .............................. Edema : ..............................
Memar : ..................................... Hematom : .....................................
b. Perineum : Utuh / Episiotoma/ Ruptur
Tanda REEDA : R : Kemerahan : Ya / Tidak
E : Bengkak : Ya / Tidak
E : Echimosis : Ya / Tidak
D : Discharge : Ya / Tidak
A : Approximate : Ya / Tidak
Kebersihan :
c. Lokia
Jumlah : ..................................................................................
Jenis / warna : ..................................................................................
Konsistensi : ..................................................................................
 d. Hemoroid
Derajat : ............................... Lokasi : ....................................
Berapa lama : ............................... Nyeri / Tidak : .........................
e. Masalah khusus : ..................................................................................
7. Ekstermitas
a. Ekstermitas atas : Edema : Ya / Tidak
b. Ekstermitas : Nyeri : Ya / Tidak
Varises : Ya / Tidak, Lokasi : .................................................
Taanda Homan (Homan’s Sign) : + / -
c. Masalah khusus : ..................................................................................
8. Eliminasi
a. Urine : kebiasaan BAK
BAK saat ini : .........................................................................................
b. BAB : kebiasaan BAB
BAB saat ini : .........................................................................................
9. Istirahat dan kenyamanan
a. Pola tidur : Kebiasaan : ................, Lama : .... jam, Frekuensi : ............
Pola tidur saat ini : .................................................................................
b. Keluhan ketidaknyamanan : Ya / Tidak, lokasi : ...................................
Sifat : ........................................, Intensitas : ..........................................
10. Mobilitas dan latihan
a. Tingkat mobilitas : ..................................................................................
b. Latihan senam : ..................................................................................
c. Masalah khusus : ..................................................................................
11. Nutrisi dan cairan
a. Asupan nutrisi : ....................................... nafsu makan : baik / tidak
b. Asupan cairan : ......................................................... cukup / kurang
c. Masalah khusus : ..................................................................................
12. Keadaan mental
a. Adaptasi psikologis : ....................................................................
b. Penerimaan terhadap bayi : ....................................................................
c. Masalah khusus : ....................................................................
13. Kemampuan menyusui : ...............................................................................
14. Obat – obtan : ...............................................................................................
.......................................................................................................................
.......................................................................................................................
15. Keadaan umum ibu
Tanda vital : TD : ....................... mmHg Nadi : ...................... x/menit
S : ....................... oC RR : ...................... x/menit
16. Jenis persalinan : ..........................................................................................
17. Proses persalinan : Kala I : ........................................ jam
Kala II : ........................................ menit
Kala III : ........................................ menit
18. Komplikasi persalinan :
Ibu : ..........................................................................................................
Janin : ..........................................................................................................
19. Lamanya ketuban pecah : .............................................................................
Kondisi ketuban : .............................................................................
C. Keadaan bayi saat lahir
1. Lahir tanggal : ..................................................................................
2. Kelahiran : Tunggal / Gemeli
3. Tindakan resusitasi : ..................................................................................
4. Plasenta : Berat : ............. gr Tali pusat panjang : ............ cm
Ukuran : ........... Jumlah pembuluh darah : ............
Kelainan : ................................................................

Nilai Apgar
Nilai
Tanda Jumlah
0 1 2
Denyut
( ) tidak ada ( ) < 100 ( ) > 100
jantung
Usaha ( ) menangis
( ) tidak ada ( ) lambat
napas kuat
Tonus ( ) ekstremitas
( ) lumpuh ( ) gerakan aktif
otot fleksi sedikit
( ) tidak ( ) gerakan ( ) reflek
Reflex
bereaksi sedikit melawan
( ) tubuh
Warna ( ) biru/pucat ( ) kemerahan
kemerahan

D. Hasil pemeriksaan penunjang :

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E. Analisa Data
Tanggal,
No Data Fokus Problem Etiologi
hari & jam

F. Diagnosa Keperawatan
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G. Intervensi Keperawatan
Dx
No NIC NOC
Kep
H. Implementasi Keperawatan
Tanggal, Dx
No Implementasi Respon TTD
hari & jam Kep
I. Evaluasi
Tanggal, Dx
No Evaluasi TTD
hari & jam Kep