ASUHAN KEPERAWATAN POSTNATAL

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DI RUANG . . . . . . . . . . . . . . . . . .
RUMAH SAKIT SMC
KABUPATEN TASIKMALAYA

Disusun untuk memenuhi tugas

Praktek Klinik Keperawatan Maternitas

Disusun oleh :
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PROGRAM STUDI ILMU KEPERAWATAN

JURUSAN KEPERAWATAN
STIKES MITRA KENCANA TASIKMALAYA
2018
 ASUHAN KEPERAWATAN POSTNATAL
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DI RUANG . . . . . . . . . . . . . . . . . .
RUMAH SAKIT SMC
KABUPATEN TASIKMALAYA

I. Pengkajian
Identitas
1. Identitas Klien
Nama Pasien : ......................................................................................
Umur : ......................................................................................
Status Marital : ......................................................................................
Suku : ......................................................................................
Agama : ......................................................................................
Pendidikan : ......................................................................................
Pekerjaan : ......................................................................................
Alamat : ......................................................................................
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Tanggal Masuk RS : ......................................................................................
Tanggal Pengkajian : ......................................................................................
No CM : ......................................................................................
Diagnosa Medis : ......................................................................................
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Identitas Penanggungjawab
Nama : ......................................................................................
Umur : ......................................................................................
Suku : ......................................................................................
Agama : ......................................................................................
Pendidikan : ......................................................................................
Pekerjaan : ......................................................................................
Alamat : ......................................................................................
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Hubungan dengan Pasien : ......................................................................................
 2. Riwayat Kesehatan
a. Keluhan Utama
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b. Riwayat Kesehatan Sekarang
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c. Riwayat Kesehatan Dahulu
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d. Riwayat Kesehatan Keluarga
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e. Riwayat Kehamilan, Persalinan dan Nifas yang lalu
1) Riwayat Kehamilan yang lalu
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2) Riwayat Persalinan
Masalah
Tgl Umur Jenis Jenis
No Penolong Keadaan
Partus Hamil Partus Kelamin Hamil Lahir Nifas Bayi
Anak
 3) Riwayat Persalinan Sekarang
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f. Riwayat Ginekologi
1) Riwayat Menstruasi/Haid
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2) Riwayat Perkawinan
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3) Riwayat Keluarga Berencana
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3. Pemeriksaan Fisik
a. Keadaan Umum
Tingkat Kesadaran :
Tekanan Darah :
Nadi :
Pernapasan :
Suhu :
b. Kepala
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c. Mata
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d. Telinga
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e. Hidung
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f. Mulut
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g. Dada
Paru-paru : ……………………………………………………………………..
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Jantung : ……………………………………………………………………..
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Payudara : ……………………………………………………………………..
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h. Abdomen
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 i. Genetalia
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j. Kulit
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k. Kuku
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l. Ekstremitas
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4. Pola Aktifitas Sehari-hari
Aktifitas Sebelum Hamil Ketika Hamil
1. Makan
- Frekuensi ............................. .............................
- Jumlah ............................. .............................
- Jenis ............................. .............................

2. Minum
- Kwantitas ............................. .............................
- Jenis ............................. .............................

3. BAK
- Frekuensi ............................. .............................
- Warna ............................. .............................

4. BAB
- Frekuensi ............................. .............................
- Warna ............................. .............................

5. Mandi
- Frekuensi ............................. .............................
- Gosok Gigi ............................. .............................
 6. Tidur
- Kualitas ............................. .............................
- Gangguan ............................. .............................

5. Aspek Psikososial dan Spiritual

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a. Konsep Diri
Gambaran Diri
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Ideal Diri
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Harga Diri
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Identitas Diri
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Peran Diri
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 b. Hubungan Komunikasi
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c. Kebiasaan Seksual
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d. Spiritual
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6. Pemeriksaan Penunjang
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II. Analisa Data
No Data Interpretasi Data Masalah
III. Diagnosa Keperawatan
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IV. Intervensi Keperawatan

No. Dx Tujuan dan Kriteria hasil Intervensi
No. Dx Tujuan dan Kriteria hasil Intervensi
V. Implementasi
Dx Tanggal/Jam Implementasi TTD
Dx Tanggal/Jam Implementasi TTD
VI. Evaluasi
Dx Tanggal Evaluasi TTD
Dx Tanggal Evaluasi TTD