Format Pengkajian Post Partum
Format Pengkajian Post Partum
IDENTITAS
Nama pasien : ................................. Nama Suami : …….....................
Umur : ....................... th Umur : ....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ……...................
Agama : ................................. Agama: ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................
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
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 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
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
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
Do.
2. Ds
Do.
3. Ds.
Do.
4. Ds.
Do.
5. Ds.
Do.
dst
PRIORITAS MASALAH
TANGGAL Nama
No Diagnosa keperawatan
ditemukan Teratasi perawat
RENCANA KEPERAWATAN
A
P
Dx. 2 :
S.
O
A
P
Dx 3 :.......
S.
O
A
P
Dx 4 :.......
S.
O
A
P
dst