FORMAT PENGKAJIAN POST PARTUM

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

IDENTITAS
Nama pasien : ................................. Nama Suami : …….....................
Umur : ....................... th Umur : ....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ……...................
Agama : ................................. Agama: ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................

STATUS KESEHATAN SAAT INI

1. Keluhan utama saat ini : ..................................................................……..................
.............................................................................................................................................
.…………………………………………………………………………………….……
2. Riwayat Kondisi saat ini

3. Diagnosa medik : ...........................................................................……....................

RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak (
)
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :
b. Riwayat kehamilan, persalinan, nifas :

Ana Kehami
Persalinan Komplikasi nifas Anak
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB pj
o long ksi han
u a ulit ulit si
n m
il
a
n

Genogram

Riwayat Persalinan Dan Post Partum Sekarang

Keluhan his
Pengeluaran pervaginan
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 mat

RIWAYAT KELUARGA BERENCANA :

Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................

RIWAYAT KESEHATAN :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................
…………….......
- Bahaya :
…………......................................................................................................................
- Lainnya sebutkan : .................................................................................
…………………….....................

ASPEK PSIKOSOSIAL :
Persepsi ibu tentang persalinan saat ini: ................................................................
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

KEBUTUHAN DASAR KHUSUS (Di rumah dan di rs) :

Pola Nutrisi
Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : ................................................................................….
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : .......................……………………………………………….
Keluhan saat BAK : .................................................………......................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : .............……………………………………………….........
Keluhan ....................................................................………....
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
Ketergantungan obat
: ..............................................................................................

PEMERIKSAAN FISIK
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : .....................................Suhu : .......…........C
Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :
Kepala : Bentuk ..........................................................
Keluhan :........................................................
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

Perineum dan Genital

 Integritas Vagina :
 Perineum : .................................................................................
..............
 Tanda REEDA
R:Rednes : ya/tidak
E:Edema : ya/tidak
E: Echimosis : ya/tidak
D: Discharge : ya/tidak
A: Approximate : baik/tidak
 Lokia : jumlah warna/jenis bau
 Hemorrhoid : derajat lokasi nyeri

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit :
 Warna kulit :
 Edema :
 Kontraktur pada persendian ekstrimitas :
 Tanda Homan : +/-
 Kesulitan dalam pergerakan :
 Lainnya sebutkan :
Kesiapan dalam perawatan bayi:
Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan

Data Penunjang
1) Laboratorium
: .................................................................................................
2) USG
: .................................................................................................
3) Rontgen : .................................................................................
................
4) Terapi yang
didapat: ..............................................................................................................................
............................................................................................................................................
...................................................................................................

Data Tambahan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................
Surabaya, ........................................
Pemeriksa

ANALISA DATA

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................

No Data Penyebab Masalah

1. Ds.

Do.

2. Ds
 Do.

3. Ds.

Do.

4. Ds.

Do.

5. Ds.

Do.

dst
PRIORITAS MASALAH

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................

TANGGAL Nama
No Diagnosa keperawatan
ditemukan Teratasi perawat
 RENCANA KEPERAWATAN

Nama Klien :...................... No Rekam Medis :....................... Hari Rawat Ke :............

No Diagnosa keperawatan Tujuan Rencana Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................
No Tgl Tindakan TT Tgl Catatan Perkembangan TT
Dx Jam Perawat Jam Perawat
Dx 1 :
S.
O

A
P
Dx. 2 :
S.
O
A
P
Dx 3 :.......
S.
O

A
P
Dx 4 :.......
S.
O

A
P

dst