A. IDENTITAS
Pasien Penanggung Jawab
Nama : Nama Suami : Ke-
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Status Pernikahan : Status Pernikahan :
Alamat : Alamat :
No. RM :
Tanggal masuk :
B. KELUHAN UTAMA
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C. RIWAYAT KEPERAWATAN
1. Riwayat Kesehatan Sekarang
Riwayat Prenatal
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Riwayat Intranatal
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Riwayat Post Natal
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2. Riwayat Kesehatan Dahulu
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c) Genogram
d) Postpartum Sekarang
Riwayat Persalinan Sekarang
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Tiper Persalinan : Spontan Bantuan, _______________________
Lama Persalinan : Kala I = _______________________
jam
Kala II = _______________________ jam
Kala III = _______________________ jam
Kala IV = _______________________ jam
e) Rencana Perawatan Bayi
Sendiri Orang tua Lainnya, _______________________
Kesanggupan dan pengetahuan dalam merawat bayi:
Breast care : __________________________________________________
Perineal care : __________________________________________________
Nutrisi : __________________________________________________
Senam nifas : __________________________________________________
KB : __________________________________________________
Menyusui : __________________________________________________
5. Riwayat Program KB
Melaksanakan KB : Tidak Ya, ____________________________
Menggunakan kontrasepsi sejak: __________________________________________
Keluhan : ____________________________________________
6. Riwayat Lingkungan
Kebersihan : __________________________________________________
Bahaya :
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Lainnya : __________________________________________________
7. Aspek Psikososial
Persepsi ibu tentang keluhan/penyakit
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Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari?
Ya Tidak
Jelaskan,
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Harapan yang ibu inginkan
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Ibu tinggal dengan, _____________________________________________________
Orang yang paling penting untuk ibu, ______________________________________
Sikap anggota keluarga terhadap keadaan saat ini, ____________________________
Kesiapan mental menjadi seorang ibu: Ya Tidak
9. Pemeriksaan Fisik
Kesadaran : Composmentis Apatis Somnolen Sopor Koma
GCS :
Vital Sign : TD : ________________ mmHg
Nadi : Frekuensi : _____________ kali/menit
Irama : regular ireguler
Kekuatan/isi : kuat sedang lemah
Respirasi : Frekuensi : ________________ kali/menit
Irama : regular ireguler
Suhu : ________________ oC
Pulmo
Inspeksi : ________________________________________________________
Palpasi : fremitus taktil ka/ki : ______________________________________
Perkusi : ka/ki : __________________________________________________
Auskultasi : vesikuler ka/ki wheezing ronkhi
Cor
Inspeksi : ________________________________________________________
Palpasi : ictus cordis : _____________________________________________
Perkusi : batas jantung :
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Auskultasi : bunyi jantung I (SI): _______________________________________
bunyi jantung II (SII) : _________________________________________________
bunyi jantung III (SIII) : ________________________________________________
Abdomen
Linea : ________________________________________________________
Striae : ________________________________________________________
Luka operasi : ________________________________________________________
Kontraksi : ________________________________________________________
Lainnya : ________________________________________________________
Eliminasi alvi
Frekuensi : ______________ Penggunaan pencahar: ____________________
Waktu : Pagi Siang Sore Malam
Warna : __________ Darah _________ Konsistensi ___________________
Ggn. eliminasi bowel: Konstipasi Diare Inkontinensia bowel
Eliminasi Uri
Frekuensi : ______________ Penggunaan pencahar _______________________
Warna : ______________ Darah ___________________________________
Ggn. eliminasi bladder : nyeri saat BAK
burning sensation
bladder terasa penuh setelah BAK
inkontinensia bladder
Riwayat penyakit dahulu : penyakit ginjal batu ginjal injury / trauma
Penggunaan kateter : Ya Tidak
Warna : normal hematuria seperti teh
Keluhan : nokturia retensi urine inkontinensia urine
Ektremitas
Atas : kekuatan otot ka/ki : ___________________________
ROM ka/ki : ____________________________________________
Capillary Refill Time : ____________________________________________
Bawah : kekuatan otot ka/ki : ___________________________
ROM ka/ki : ____________________________________________
Capillary Refill Time : ____________________________________________
D. PEMERIKSAAN PENUNJANG
Laboratorium
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USG
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Rontgen
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E. TERAPI MEDIK
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F. DATA TAMBAHAN
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