Format Pengkajian Post Natal - 021556
Format Pengkajian Post Natal - 021556
KEPERAWATAN MATERNITAS
Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal :
Pengkajian :
Praktik :
I. IDENTITAS PASIEN
Nama (Inisial) : ......................................................
Umur : .......................................................
Status Perkawinan : ......................................................
Agama : ......................................................
Suku : ......................................................
Pendidikan : .......................................................
Nama Suami : ......................................................
Umur Suami : .......................................................
Alamat : ......................................................
Pekerjaan : ......................................................
Diagnosa Medis : ......................................................
Tanggal Masuk RS : .......................................................
II. KELUHAN UTAMA
..........................................................................................
III. RIWAYAT PERSALINAN DAN KELAHIRAN SAAT INI
a. Lama persalinan : .......................................................................
b. Posisi fetus : .........................................................................
c. Tipe kelahiran : .........................................................................
d. Penggunaan analgetik dan anastesi : ........................................
e. Masalah selama persalinan : ......................................................
1
Trimester III : ............................................................................................................
2
o Hemorrhoid: derajat……lokasi…….berapa lama….
nyeri: ya/tidak
Masalah khusus....................
Keadaan Mental
a. Adaptasi psikologis :..............................................................
b. Penerimaan terhadap bayi:......................................................
c. Masalah khusus : ....................................................................
f. Hubungan-Peran
.................................................................................................
g. Seksualitas-Reproduksi
.................................................................................................
3
XIII. KELUARGA BERENCANA
............................................................................................................
4
ANALISA DATA
5
DIAGNOSA KEPERAWATAN
6
INTERVENSI KEPERAWATAN
7
IMPLEMENTASI DAN EVALUASI KEPERAWATAN
8
9