UJIAN KEPERAWATAN MATERNITAS

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 FORMAT PENGKAJIAN POST PARTUM

Nama Mahasiswa : ..........................................................................................

Nim : ..........................................................................................

Tanggal Pengkajian & Jam : ..........................................................................................

A. Pengumpulan data

a. IDENTITAS KLIEN
Nama : Lilis Andriani................................................................

Tempat/Tgl lahir : Sebangau, 21 Agustus 1994..........................................

Agama : Islam..............................................................................

Suku/Bangsa : Jawa/Indonesia..............................................................

Pendidikan terkahir : D3..................................................................................

Pekerjaan : PNS...............................................................................

Gol. Darah : O....................................................................................

Alamat : Jl. Poros Desa Gandang.................................................

Diagnosa Medis : .......................................................................................

Penghasilan perbulan : 2.300.000........................................................................

Tanggal masuk RS : 31-10-2020....................................................................

Tanggal Pengkajian : .......................................................................................

Nomor Medrek : .......................................................................................

 b. IDENTITAS SUAMI
Nama : Samsul Ariyadi..............................................................

Umur : 26 tahun.........................................................................

Jenis kelamin : Laki-laki........................................................................

Agama : Islam..............................................................................

Suku Bangsa : Jawa/Indonesia..............................................................

Pendidikan terakhir : SLTA.............................................................................

Pekerjaan : Wiraswasta....................................................................

Gol. Darah : O....................................................................................

Alamat : Jl. Poros Desa Gandang.................................................

b. Status Kesehatan
a. Keluhan utama : Sakit perut mau melahirkan kencang2 menjalar sampai ke
pinggang sejak pukul 06.00 pagi disetai keluar lendir darah dari jalan lahir...............

................................................................................................................................

b. Riwayat Kesehatan sekarang : (PQRST)

c. Riwayat Kesehatan yang lalu

d. Riwayat Kesehatan keluarga

Genogram 3 generasi : .......................................................................................
e. Riwayat obstetric dan ginekologi
1. Riwayat Ginekologi

a. Riwayat Menstruasi :

- Menarche 14 tahun………………………. Lamanya haid : 5-7

hari……………….

- Siklus : 30………………………… Banyaknya : 2-3x ganti

pembalut/hari………………….

- Sifat darah (warna, bau/gumpalan, dysmenorhoe) : merah hati bercmapur

lendir…………………….

- HPHT : 06-02-
2020…………………………………………………………………

- Taksiran persalinan : 13-11-

2020……………………………………………………

b. Riwayat Perkawinan : (suami dan isteri)sah

- Lamanya pernikahan : 1 bulan...........................................................

- Pernikahan yang ke : 1.....................................................................

c. Riwayat Keluarga Berencana :

- Jenis kontrasepsi apa yang digunakan sebelum hamil:tidak ada.............

- Waktu dan lamanya penggunaan : .........................................................:

- Apakah ada masalah dengan cara tersebut : ..........................................

- Jenis, kontrasepsi yang direncanakan setelah persalinan sekarang :........

 - Berapa jumlah anak yang direncanakan oleh keluarga : 2.......................

2. Riwayat Obstetri

a. Riwayat kehamilan, persalinan dan nifas yang lalu : G…P….A….

No Umur Jenis Tempat/ Jenis

Tgl Partus BB Ket
Hamil Partus Penolong Kelamin

b. Riwayat Kehamilan sekarang :

- Keluhan waktu hamil : mual muntah.....................................................

- Imunisasi : TT langkap..........................................................................

- Penambahan BB selama hamil :13 kg......................................................

- Pemerikasaan Kehamilan :Teratur/Tidak.................................................

- Tempat pemeriksaan dan hasil pemeriksaan :bidan.................................

 c. Riwayat Persalinan sekarang :

- P…………………… A………………………

- Tanggal melahirkan :…………………….Jam ……………………….

- Jenis Persalinan : ……………………….. Lamanya persalinan :……...

- Penyulit Persalinan : .............................................................................

- Pendarahan : ..........................................................................................

- Jenis kelamin bayi :………,BB :………….., APGAR Score :…………

3. Pemerikasaan Fisik

3.1. Ibu
i. Keadaan umum - Suhu………………………….…..0C
- Nadi…………………………x/menit
- Pernapasan :…………………x/menit

- Tekanan Darah………………x/menit

- BB sebelum hamil………….kg

- BB : ………………………..kg

- Tinggi badan : …….……………Cm

- Kesadaran : ……...………………….

- Turgor Kulit : ……………………….

ii. Kepala - Warna rambut :

.......................................................................-
Keadaan :.......................................................
.......................................................................
c. Muka..........................................................................................................-
Oedema : ..........................................................................................................
..........................................................................................................................
..........................................................................................................................-
Cloasma gravidarum :......................................................................................

d. Mulut..........................................................................................................-
Mukosa mulut & bibir :....................................................................................
..........................................................................................................................-
Keadaan gigi :...................................................................................................
..........................................................................................................................-
Fungsi pengecapan :.........................................................................................
..........................................................................................................................-
Keadaan mulut :................................................................................................
..........................................................................................................................-
Fungsi menelan :..............................................................................................
e. Mata............................................................................................................-
Konjunctiva:.....................................................................................................
..........................................................................................................................
..........................................................................................................................-
Sklera :..............................................................................................................
..........................................................................................................................
..........................................................................................................................-
Fungsi Pengelihatan:........................................................................................

f. Hidung.........................................................................................................-
Pendarahan/Peradangan :.................................................................................
..........................................................................................................................-
Keadaan/kebersihan
g. Telinga........................................................................................................-
Keadaan :..........................................................................................................
..........................................................................................................................
..........................................................................................................................-
Fungsi pendengaran :........................................................................................

h. leher............................................................................................................-
Pembesaran kel. Tyroid :..................................................................................
..........................................................................................................................-
Distensi Vena Jugularis:...................................................................................
..........................................................................................................................-
Pemebesaran KGB : ........................................................................................
i. Daerah dada.................................................................................................-
Suara napas :.....................................................................................................
..........................................................................................................................
..........................................................................................................................-
Jantung dan paru-paru......................................................................................-
Bunyi jantung :.................................................................................................
..........................................................................................................................
..........................................................................................................................-
Retraksi dada :..................................................................................................
..........................................................................................................................-
Payudara...........................................................................................................-
Perubahan :.......................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................-
Bentuk buah dada :...........................................................................................
..........................................................................................................................
..........................................................................................................................-
Hyperigmentasi areola :....................................................................................
..........................................................................................................................
..........................................................................................................................-
Keadaan puting susu :.......................................................................................
..........................................................................................................................
..........................................................................................................................-
Cairan yang keluar :.........................................................................................
..........................................................................................................................
..........................................................................................................................-
Keadaan/Kebersihan :.......................................................................................
..........................................................................................................................
..........................................................................................................................-
Nyeri/Tegang :..................................................................................................
..........................................................................................................................
..........................................................................................................................-
Skala nyeri : .....................................................................................................
..........................................................................................................................
j. Abdomen - Tinggi FU : ………………………..

..........................................................................................................................
..........................................................................................................................-
Kontraksi Uterus :............................................................................................
..........................................................................................................................
..........................................................................................................................-
Konsistensi Uterus :.........................................................................................
..........................................................................................................................
..........................................................................................................................-
Posisi Uterus :...................................................................................................
..........................................................................................................................
..........................................................................................................................-
Diastasis RA :...................................................................................................
..........................................................................................................................
..........................................................................................................................-
Bising usus :……………..…x/menit
k. Genetalia Eksterna

Keluhan :…………………….. - Oedema :……………………………

- Varises : ……………………………

..........................................................................................................................
..........................................................................................................................-
Pembesaran Kel Bartolin :................................................................................
..........................................................................................................................
..........................................................................................................................-
Pengeluaran/lochea :.........................................................................................
..........................................................................................................................
..........................................................................................................................
Warna :.............................................................................................................
..........................................................................................................................
..........................................................................................................................
Jumlah :............................................................................................................
..........................................................................................................................
.......................................................................................................................... Bau
:.........................................................................................................................
..........................................................................................................................
..........................................................................................................................-
Blas :................................................................................................................
..........................................................................................................................

l. Anus - Haemorrhoid : ..................................

m. Ekstermitas Atas & Bawah

..........................................................................................................................
..........................................................................................................................-
Refleks patela : ................................................................................................
 ..........................................................................................................................
..........................................................................................................................-
Varises :............................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................-
Oedema :...........................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................-
Simetris :...........................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................-
Kram :...............................................................................................................
..........................................................................................................................

3.2. Bayi
1. Keadaan umum : .......................................................................
2. Tanda-tanda vital : .......................................................................
3. Kepala : .......................................................................
4. Dada : .......................................................................
5. Abdomen : .......................................................................
6. Genetalia : .......................................................................
7. Anus : .......................................................................
8. Ekstremitas : .......................................................................

4. Pola Aktivitas Sehari-hari

a. Pola Nutrisi
- Frekuensi makan :......................................................................
 - Jenis makanan :......................................................................
- Makanan yang disukai :......................................................................
- Makanan yang tidak disukai :......................................................................
- Makanan pantang / alergi :......................................................................
- Nafsu makan :......................................................................
- Porsi makan :......................................................................
- Minum (jumlah dan jenis) :......................................................................

b. Pola Eliminasi
1. Buang Air Besar (BAB)
- Frekuensi :......................................................................
- Warna :......................................................................
- Bau :......................................................................
- Konsistensi :......................................................................
- Masalah / Keluhan :......................................................................

2. Buang Air Kecil (BAK) :......................................................................

- Frekuensi :......................................................................
- Warna :......................................................................
- Bau :......................................................................
- Masalah / Keluhan :......................................................................

c. Pola tidur dan istirahat

- Waktu tidur
- Lama tidur/hari
- Kebiasaan pengantar tidur
- Kebiasaan saat tidur
- Kesulitan dalam tidur
:......................................................................
:......................................................................
:......................................................................
:......................................................................
:......................................................................

d. Pola aktivitas dan latihan

- Kegiatan dalam pekerjaan :......................................................................
 - Olah raga :......................................................................
- Mobilisasi dini :......................................................................
- Kegiatan di waktu luang :......................................................................
- Menyusui (posisi, cara, frekuensi) : ……………………………………………

e. Personel Hygiene
- Kulit :......................................................................
- Rambut :......................................................................
- Mulut dan Gigi :......................................................................
- Pakaian :......................................................................
- Kuku :......................................................................

f. Ketergatungan fisik
- Merokok :......................................................................
- Minuman keras :......................................................................
- Obat-obatan :......................................................................
- Lain-lain :......................................................................

5. Aspek Psikososial dan Spiritual

a. Pola pikir dan persepsi
- Apakah ibu telah mengetahu cara memberi ASI dan memberi makanan
tambahan pada bayi :...................................................................................
- Apakah ibu merencanakan pemberiaan ASI pada bayinya :.......................
- Jenis kelamin yang diharapkan :.................................................................
- Siapa yang membantu merawat bayi dirumah :.........................................
- Apakah ibu telah mengetahui nutrisiibu menteteki :...................................
- Apakah hamil ini diharapkan :....................................................................
- Apakah ibu merencanakan untuk mengimunisasikan bayinya :.................
- Apakah ibu telah mengetahui cara memandikan dan merawat tali pusat :
.....................................................................................................................
b. Persepsi diri
- Hal yang amat dipikirkan saat ini :.............................................................
- Harapan setelah menjalani perawatan :.......................................................
- Perubahan yang dirasa setelah hamil :........................................................
c. Konsep diri
- Body image :...............................................................................................
- Peran :..........................................................................................................
- Ideal diri :....................................................................................................
- Identitas diri :..............................................................................................
- Harga diri :.................................................................................................
d. Hubungan/Komunikasi
- Bicara : jelas/relevan/mampu mengekpresikan/mampu mengerti orang lain :
.....................................................................................................................
- Bahasa utama :……………….Bahasa daerah............................................
- Yang tinggal serumah :...............................................................................
- Adat istiadat yang dianut :...........................................................................
- Yang memegang peranan penting dalam keluarga :...................................
- Motivasi daru suami :..................................................................................
- Apakah suami perokok :..............................................................................
- Kesulitan dalam keluarga :..........................................................................

e. Kebiasaan Seksual
- Gangguan hubungan seksual :.....................................................................
- Pemahaman terhadap fungsi seksual post partum :.....................................
f. Sistem nilai - kepercayaan
- Siapa dan apa sumber kekuatan :................................................................
- Apakah Tuhan, agama, Kepercayaan penting untuk anda :........................
- Kegiatan agama atau kepercayaan yang dilakukan (macam frekuensi) sebutkan
:....................................................................................................................
- Kegiatan agama atau kepercayaan yang dilakukan selama di Rumah Sakit,
sebutkan :....................................................................................................
6. Pemerikasaan Penunjang
a. Darah
- HB : ……………….. Golongan darah/Rh..............................
- Gula darah : ……………….. Leukosit :.............................................
b. Urine
- Protein : ……………….. Sedimen :.............................................
- Reduksi : ………………..
c. Pemeriksaan tambahan
- Rontgent : ..........................................................................................

7. Pengobatan
.................................................................................................................................
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Palangka Raya, ………………………

Mahasiswa
( …………………………… )
DIAGNOSA/MASALAH POTENSIAL TINDAKAN SEGERA
 ASUHAN KEPERAWATAN
Ny…………………………………

INTERPRETASI DATA

TANGGAL DATA DASAR DIAGNOSA MASALAH

DO.

DS.
 ASUHAN KEPERAWATAN
Ny…………………………………

Diagnosa Intervensi Implementasi Evaluasi

1. S.

2. O.

dst A.

P.