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
.............................................................................................................................................
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 : Penuh / Kosong
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 :............................................................................
Yang melakukan
Pengkajian
(…………………………
………………….)
NIM