KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN JAMBI

JURUSAN KEPERAWATAN
Jl. Dr. Tazar No. 05 Kel.BuluranKenali Jambi – 36123 Telp. 0741 65816

PENGKAJIAN KEPERAWATAN KLIEN DALAM MASA NIFAS

TANGGAL PENGKAJIAN :....................................
NAMA MAHASISWA :...........................
TANGGAL :....................................
NIM :...........................
JAM MASUK :....................................
RUANGAN/KELAS :....................................
NOMOR KAMAR :....................................
NOMOR REGISTRASI :....................................
TANDA TANGAN :.............................
DIAGNOSA MEDIS :....................................

I. BIODATA
a. NamaIbu :.............................................................................................................
b. Umur :.............................................................................................................
c. Agama :.............................................................................................................
d. Pendidikan :.............................................................................................................
e. Pekerjaan :.............................................................................................................
f. Suku/Bangsa :.............................................................................................................
g. AlamatRumah :.............................................................................................................
h. NamaSuami :.............................................................................................................
i. Umur :.............................................................................................................
j. Agama :.............................................................................................................
k. Pendidikan :.............................................................................................................
l. Pekerjaan :.............................................................................................................
m. AlamatRumah :.............................................................................................................
 II. KELUHAN UTAMA / ALASAN MASUK RUMAH SAKIT
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III. RIWAYAT KESEHATAN SEKARANG (PQRST)

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IV. RIWAYAT KEHAMILAN

1. Gravida……………….Para :………….…………..AB...........................................:

2. UmurKehamilan :..................................Minggu
3. TaksiranKehamilan :...................................................................................
4. ANC (Ya / Tidak) :.........................................Frekuensi ……………...
5. MasalahKesehatanUmum :...................................................................................
6. PenyakitKehamilan :...................................................................................
7. HasilKehamilan Yang Lain :...................................................................................

V. RIWAYAT PERSALINAN
1. TanggalPersalinan :.................................... Jam …………………..
2. Type Persalinan :............................................................................
3. Lama Persalinan :............................................................................
4. JumlahPerdarahan :............................................................................
5. PerawatandanPengobatan yang
Diberikan? :............................................................................
.............................................................................
.............................................................................

6. PenyulitPersalinan :............................................................................
7. JenisBayi :............................... BB Lahir ………………...
8. Apgar Score :...................... 1 Menit ………………..5 Menit
VI. KEADAAN POST PARTUM
1. KeadaanUmum :............................................................................
2. Tanda-tanda Vital
a. TekananDarah :............................................................................
b. Nadi :............................................................................
c. Suhu :............................................................................
d. Pernafasan :............................................................................
3. Buah Dada
a. Konsistensi :............................................................................
b. Putting Susu :............................................................................
c. ASI / Colostrum :............................................................................
d. Kelainan :............................................................................
4. Uterus
a. Kontraksi :............................................................................
b. Posisi :............................................................................
c. Tinggi Fundus Uteri :............................................................................
5. Lochea
a. Warna / Jenis :............................................................................
b. Banyak :............................................................................
c. Bau :............................................................................
6. Vulva
a. Oedema :............................................................................
b. Luka :............................................................................
7. Perineum
a. Efisiotomi :............................................................................
b. Jenisefisiotomi :............................................................................
c. Jahitan :............................................................................
d. Tanda-tandaInfeksi :............................................................................
8. Haemorrhoid ( Ya / Tidak ) :............................................................................
 9. Ekstremitasbawah 9 Ya / Tidak ) : oedema :……………….………. Varices :
………….……………..
10. Ambulasi
11. Diet / NafsuMakan
12. VesicaUrania
13. Eleminasi BAK
a. Frekuensi
b. Kesulitan
c. UpayaMengatasinya
14. Eliminasi BAB
a. Frekuensi
b. Kesulitan
c. UpayaMengatasinya
15. Section Caesaria
16. Keadaan Luka Operasi
a. Tanda-tandaInfeksi
VII. DATA PSIKOLOGIS
a. Sedih…………………………………….
……………………………………………………………………………
b. Konsepdiri
c. HubungandenganBayi
d. HubungandenganKeluarga
e. Self Care
i. Perawatanbuah dada
ii. Perawatan Perineum
:............................................................................
:............................................................................
: Penuh / Kosong
:............................................................................
:............................................................................
:............................................................................
:............................................................................
:............................................................................
:............................................................................
:............................................................................
:............................................................................
Cemas
:............................................................................
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:............................................................................
:............................................................................
:............................................................................
: Mengerjakan :................................................
Memahami :................................................
: Mengerjakan :................................................
Memahami :................................................
 iii. PerawatanBayi : Mengerjakan :................................................
Memahami :................................................

VIII. KELUHAN – KELUHAN

IX. DATA PENUNJANG
a. Diagnose Medis :............................................................................
b. PemeriksaanKhusus :............................................................................
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Yang melakukan
Pengkajian

(…………………………
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NIM