ASUHAN KEPPERAWATAN POST SC

(SECTIO CAESAREA)

Nama Mahasiswa :
NIM :

A. PENGKAJIAN
I. IDENTITAS
Nama Pasien :
Umur :
Suku Bangsa :
Agama :
Pendidikan :
Pekerjaan :
Alamat Rumah :

Nama Suami :
Umur :
Suku :
Agama :
Pendidikan :
Pekerjaan :

II. Anamnese Tanggal

1. Alasan Kunjungan :

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Keluhan Utama :
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2. Riwayat Kesehatan
a. Riwayat Kesehatan Sekarang
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b. Riwayat Kesehatan Dahulu
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c. Riwayat Kesehatan Keluarga
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GENOGRAM

3. Riwayat Kehamilan Sekarang

Ibu G: P: A:
Pada hamil muda : ...........................................................................
Pada Hamil Tua : ...........................................................................

4. Riwayat Menstruasi
Menarche : ..................... Tahun
Siklus : ..................... Hari
Lamanya : ..................... Hari
Banyaknya : ...........................................................................
Sifat Darah : ...........................................................................
Warna : ...........................................................................
HPHT : ...........................................................................

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 TTP : ..............................................................

2. Riwayat Perkawinan
Status Perkawinan : ...........................................................................
Umur ketika Perkawinan : ...........................................................................
Lamanya : ...........................................................................
3. Riwayat Kehamilan dan Persalinan yang lalu

Kehamilan Persalinan Nifas Keadaan Anak

UmurKeha ANC Cara Penyulit Pandamp Penyulit Lectasi Sex BB Umur
milan ing Lahir Sekaran
g

4. Riwayat KB
Jenis Kontrasepsi : .......................................................................................
Efek Samping : .......................................................................................
Lama Perkawinan : .......................................................................................
Alasan di Stop : .......................................................................................

5. Riwayat Ginekologi
Tumor : .......................................................................................
Penyakit Kelainan : .......................................................................................
Sipilis : .......................................................................................
Herpes : .......................................................................................
6. Riwayat Kesehatan yang lalu
Penyakit yang sudah pernah di derita : DM ( ) TBC ( ) Jantung
() Epilepsi ( ) Asma ( ) Hepatitis ( )

Pemeriksaan Fisik
1. Pemeriksaan Umum
Kesadaran : .......................................................................................
Suhu : .......................................................................................
TD : .......................................................................................
Nadi : .......................................................................................
Pernapasan : .......................................................................................
TB : .......................................................................................
BB saat ini : .......................................................................................

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 BB Sebelum Hamil : .......................................................................................
2. Pemeriksaan Sistematik
Kepala :
- Rambut : .......................................................................................
- Muka : .......................................................................................
- Mata : .......................................................................................
- Hidung : .......................................................................................
- Telinga : .......................................................................................
- Mulut : .......................................................................................
Leher :
- Kelenjar Tyroid : .......................................................................................
- Kelenjar Getah Bening: .......................................................................................
- Payudara : .......................................................................................
- Mammae : .......................................................................................
- Areola Mammae : .......................................................................................
- Putting Susu : .......................................................................................
3. Pemeriksaan Khusus Obstetri
Abdomen
a. Inspeksi : .......................................................................................
b. Palpasi : .......................................................................................
Leopold I : .......................................................................................
Leopold II : .......................................................................................
Leopold III : .......................................................................................
Leopold IV : .......................................................................................
Kontraksi : .......................................................................................
Gerakan Anak : .......................................................................................
TBJ ( Taksiran Berat Janin ) : .......................................................................................
c. Auscultasi : .......................................................................................
d. Pemeriksaan Panggul Luar: .......................................................................................
1. Distansia Spinarum : .......................................................................................
2. Distansia Kristanum : .......................................................................................
3. Conjungata Externa : .......................................................................................
4. Lingkaran Panggul : .......................................................................................

Genetalia Externa
Inspeksi

- Varices : .......................................................................................
- Oederma : .......................................................................................

Data Penunjang / Laboratorium

- Darah : .......................................................................................
Hb : .......................................................................................
Gol . Darah : .......................................................................................
- Urine : .......................................................................................
Protein : .......................................................................................
Reduksi : .......................................................................................

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- USG : .......................................................................................
III. a. Persepsi dan Harapan Klien sehubungan dengan Kehamilan.
1. Mengapa ibu datang ke Klinik
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2. Apakah kehamilan ini menimbulkan perubahan kehidupan sehari-hari bila ya
bagaimana .................................................................................................................
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3. Harapan apa yang ibu inginkan selama masa kehamilan ?
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4. Ibu tinggal dengan siapa ?
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5. Siapa yang terpenting bagi Ibu ?

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6. Dengan kunjungan Ibu ke Klinik dampak apa yang terjadi bagi keluarga ?
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7. Apakah suami atau orang terdekat mau menemani ke Klinik ?
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8. Rencana melahirkan Dimana ?
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9. Apakah ibu merencanakan untuk menyusui bayi ?
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10. Apakah ibu sudah di imunisasi ?kapan ?dan apa jenisnya ? dan berapa kali
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11. Apakah ibu memelihara kucing ?dan siapa yang membersihkan kucingnya ?
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III.b. Kebutuhan Dasar Khusus

1. Ketidaknyamanan
a) Apakah terjadi gangguan kenyamanan sejak terjadi kehamilan?
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b) Apa yang ibu inginkan dari perawat untuk menghilangkan rasa tidak nyaman
tersebut
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2. Istirahat Tidur
a) Adakah gangguan istirahat tidur selama kehamilan ?
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b) Apakah selalu ada gangguan unuk tidur ?
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c) Apakah ibu suka tidur siang ?
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3. Hygiene Pre Natal
a) Jelaskan cara mandi ?
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b) Jelaskan cara menggosok gigi ?
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c) Bagaimana ibu merawat kulit ?

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4. Keselamatan
a) Pergerakkan
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b) Penglihatan
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c) Pendengaran
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5. Cairan
a) Apakah ada perubahan jumlah cairan yang anda minim selama kehamilan ?
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b) Minuman apa yang anda sukai ?
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c) Minuman apa yang tidak di sukai ?
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6. Nutrisi
a) Gigi dan mulut
- Bagaimana keadaan gigi ibu ?
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- Apakah ibu menggunakan gigi palsu ?
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b) Nafsu makan

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- Apakah kehamilan ini mempengaruhi cara makan ibu ?
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- Apakah makanan utama ibu ?
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- Apakah ibu mempunyai makanan pantangan ?
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- Apakah ibu pernah diet ?
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7. Eliminasi
a) Apakah ada masalah BAB dan BAK dalam kehamilan ini ?
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b) Berapah kali BAB dan BAK sehari ?
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c) Apakah ibu pernah menggunakan pencahar/klisma dalam masalah BAB ?
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8. Oksigen
a) Apakah ibu mengalami gangguan pernapasan selama kehamilan ini ?
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9. Seksual
a) Apakah kehamilan menimbulkan perubahan sebagai istri
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IV. Penekanan bantuan perawatan

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1. Harapan Klien / bantuan yang diinginkan Klien terhadap Perawat ?

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