FORMAT PENGKAJIAN POSTPARTUM

A. Biodata
Nama : ..............................................................................................
Jenis Kelamin : ..............................................................................................
Umur : ..............................................................................................
Pekerjaan : ..............................................................................................
Agama : ..............................................................................................
Pendidikan Terakhir : ..............................................................................................
Alamat : ..............................................................................................
No. registrasi : ..............................................................................................
Tgl. MRS : ..............................................................................................
Tgl. pengkajian : ..............................................................................................
Diagnosa medis : ..............................................................................................

B. Riwayat Kesehatan Klien

1. Keluhan utama
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2. Riwayat penyakit dahulu
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3. Riwayat penyakit sekarang
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4. Riwayat penyakit keluarga
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C. Riwayat Kebidanan
1. Riwayat haid

Akademi Keperawatan Pemerintah Kota Pasuruan 1

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2. Riwayat perkawinan
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3. Riwayat penggunaan KB
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D. Riwayat Kehamilan / Persalinan dan Nifas yang lalu

a. Riwayat kehamilan yang lalu
Dengan Jenis keluhan pada
Anak Kehamilan berakhir
suami tribulan ke-
ke-
ke- I II III Aterm Premature Mati Hidup

b. Riwayat persalinan yang lalu

Nifas
Anak Cara Tanggal Jenis (Lamanya
Penolong BBL AS
ke- melahirkan lahir kelamin dan
masalah)

E. Pemeriksaan Kehamilan / Persalinan / Nifas sekarang

1) Kehamilan sekarang
a. HPHT : ...................................................................................................
b. Keluhan pada saat hamil (Tribulan I, II, III): .........................................
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c. Taksiran tgl persalinan : .........................................................................

Akademi Keperawatan Pemerintah Kota Pasuruan 2

 d. Pemeriksaan Leopold : ...........................................................................
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e. ANC di ...................................................................................................
jumlah kunjungan ...................................................................................

2) Persalinan sekarang
a. Cara persalinan : .....................................................................................
b. Tanggal persalinan: .................................................................................
c. Penolong : ...............................................................................................
d. BBL : ......................................................................................................
e. Jenis kelmain anak : ...............................................................................
f. AS : .........................................................................................................
g. Jumlah perdarahan : ...............................................................................

3) Nifas sekarang
a. Kontraksi uterus : ...................................................................................
b. Jumlah dan jenis lochea: ........................................................................
c. Proses laktasi : ........................................................................................
d. Keluhan / masalah pada saat nifas : .......................................................
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F. Data KB
a. Kontrasepsi yang pernah digunakan :.......................................................................
b. Lamanya : .................................................................................................................
c. Keluhan yang dirasakan : .........................................................................................
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d. Kontrasepsi yang dipilih setelah persalinan ini : .....................................................

G. Pola – pola Fungsi Kesehatan

a. Pola persepsi dan tata laksana hidup sehat
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b. Pola nutrisi (makan dan minum)
SMRS : ....................................................................................................................
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MRS : ......................................................................................................................
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c. Pola eliminasi (urine dan alvi)
SMRS : ....................................................................................................................
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MRS : ......................................................................................................................
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d. Pola tidur dan istirahat

Akademi Keperawatan Pemerintah Kota Pasuruan 3

 SMRS : ....................................................................................................................
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MRS : ......................................................................................................................
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e. Pola kebersihan diri
SMRS : ....................................................................................................................
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MRS : ......................................................................................................................
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f. Pola aktivitas
SMRS : ....................................................................................................................
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MRS : ......................................................................................................................
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g. Pola hubungan dan peran
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h. Pola persepsi dan konsep diri
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i. Pola sensori dan kognitif
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j. Pola penanggulangan stress
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k. Pola tata nilai dan kepercayaan
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H. Pemeriksaan Fisik
a. Status kesehatan umum
1) Kesadaran :
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2) TTV :
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3) TB :
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4) BB :
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b. Pemeriksaan Head to Toe

1) Kepala dan rambut :
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Akademi Keperawatan Pemerintah Kota Pasuruan 4

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2) Wajah :
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3) Mata :
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4) Telinga :
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5) Mulut :
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6) Leher :
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7) Thorak :
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8) Payudara :
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9) Abdomen :
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10) Genetalia :
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Akademi Keperawatan Pemerintah Kota Pasuruan 5

 11) Ekstremitas :
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12) Integument :
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c. Pemeriksaan penunjang
1) Laboratorium
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2) USG
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3) Dll
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d. Terapi/ pengobatan
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Akademi Keperawatan Pemerintah Kota Pasuruan 6

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Perawat

NIM.

Akademi Keperawatan Pemerintah Kota Pasuruan 7