STIKES KENDEDES MALANG

DEPARTEMEN KEPERAWATAN MATERNITAS

PENGKAJIAN POSTPARTUM

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktek :

DATA UMUM
1. Initial Klien:....................................................
2. Usia:...............................................................
3. Status Perkawinan:........................................
4. Pekerjaan :........................................
5. Pendidikan Terakhir:......................................
Initial Suami:.......................................................
Usia:....................................................................
Status Perkawinan:.............................................
Pekerjaan:..........................................................
Pendidikan Terakhir:...........................................

Riwayat Kehamilan dan Persalinan Yang Lalu

No Tahun Jenis Persalinan Penolong Jenis Keadaan Bayi Waktu Lahir Masalah Kehamilan
1
2
3
4
5
Pengalaman menyusui: ya/tidak Berapa lama:..........................................

Riwayat Kehamilan Saat Ini

1. Berapa kali periksa hamil:..........................................
2. Masalah kehamilan:....................................................
Riwayat Persalinan
1. Jenis Persalinan: Spontan (letkep/letsu)/SC a/i..............................................................................
2. Jenis kelamin bayi: L/P, BB/PB................gr/Cm, A/S............................................
3. Perdarahan:...................cc
4. Masalah dalam pesalinan:.....................................................................................
Riwayat Ginekologi
1. Masalah Ginekologi:..................................................................................................
2. Riwayat KB:...............................................................................................................

DATA UMUM KESEHATAN SAAT INI

Status Obstetrik: G......P...........Ab.......... Minggu:..................................................
Keadaan Umum:.................................Kesadaran:......................BB/TB..............Kg/.....................Cm
Tanda Vital:
TD:............................mmHg Suhu:............oC
Nadi:..............................x/menit Pernafasan:............x/menit
Kepala Leher
Kepala:......................................................................................................................................
Mata:.........................................................................................................................................
Hidung:......................................................................................................................................
Mulut:........................................................................................................................................
Telinga:......................................................................................................................................
Leher:........................................................................................................................................
Masalah Khusus:.......................................................................................................................
Dada
Jantung:.....................................................................................................................................
Paru :.......................................................................................................................................
Payudara:..................................................................................................................................
Putting Susu:.............................................................................................................................
Pengeluaran ASI:......................................................................................................................
Masalah Khusus:.......................................................................................................................
Abdomen
Involusio Uterus
Tinggi Fundus Uteri (TFU):.................................Cm Kontraksi: ya/tidak Posisi:...................
Kandung kemih:.......................................................................................................................
Fungsi Pencernaan:.................................................................................................................
Masalah Khusus:......................................................................................................................
Perineum dan Genital
Vagina: integritas kulit.........................edema...............memar..............hematom....................
Perineum: utuh/episiotomi/ruptur
Tanda REEDA:
R: kemerahan: ya/tidak
E: bengkak: ya/tidak
E: Ecimosis: ya/tidak
D: discharge: serum/pus/darah/tidak ada
A: approximate: baik/tidak
Kebersihan:..................................................
 Lochea
Jumlah:....................................................
Jenis:.....................................................
Konsistensi:.............................................
Bau:........................................................
Hemorrhoid: derajat:...................lokasi:....................berapa lama...........................nyeri/tidak
Masalah Khusus:...............................................................................
Ekstremitas
Ekstremitas Atas
Edema: ya/tidk, lokasi:.....................................................
Varises: ya/tidak, lokasi...................................................
Ekstremitas Bawah
Edema: ya/tidk, lokasi:.....................................................
Varises: ya/tidak, lokasi...................................................
Refleks Patela: +/-, jika ada +1, +2, +3, +4
Tanda Homan: +/-
Masalah Khusus:...................................................................
Eliminasi
Urine: kebiasaan BAK.................................................nyeri/tidak
BAB: kebiasaan BAB..................................................konstipasi/tidak
Istirahat dan Kenyamanan
Pola Tidur: kebiasaan tidur, lama...........jam............frekuensi.......pola tidur saat ini................
Keluhan ketidaknyamanan: ya/tidak, lokasi...........................sifat....................intensitas.........
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 bayi:...............................................
Masalah Khusus:................................................................
Kemampuan Menyusui:.................................................................
Obat-obatan yang dipakai saat ini:.......................................................................................................
Keadaan umum Ibu:............................................................. Tanda Vital: TD:.............mmHg
Suhu:............oC,
Nadi:..........x/menit
RR:............x/menit
Jenis persalinan:..................................................Proses persalinan:..................................
Kala I: ...........jam
Indikasi:................Kala II:.........menit
Komplikasi persalinan : ibu:............................................Janin:...............................
Lamanya ketuban pecah:............................................Kondisi ketuban:..............................

KEADAAN BAYI SAAT LAHIR

Lahir tanggal:...................................Jam..................Sex................
Kelahiran : (tunggal/gemeli)

NILAI APGAR
TANDA NILAI Jumlah
0 1 2
Denyut jantung o () Tidak ada o () < 100 o () >100
Usaha nafas o () Tidak ada o () Lambat o () Menangis kuat
Tonus otot o () Lumpuh o () Extr.fleksi sedikit o () Gerakan aktif
Iritabilitas refleks o () Tidak bereaksi o () Gerakan sedikit o () Reaksi melawan
Warna o () Biru/pucat o () Tubuh kemerahan, o () Kemerahan
tangan, dan kaki biru
Ket: 0 penilaian menit ke-1, () penilaian menit ke-5
Tindakan resusitasi:...............................................
Plasenta: berat...........................Tali pusat: panjang.............Cm
Ukuran:.......................................Jumlah pembuluh darah:.............................
Kelainan:........................................................................................................

Hasil pemeriksaan penunjang:.............................................................................................................

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RANGKUMAN HASIL PENGKAJIAN

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