FORMAT PENGKAJIAN POST NATAL

I. Data Umum Klien

1. Initial Pasien : _________________ Initial Suami : _________________
2. Usia : _________________ Usia : _________________
3. Status Perkawinan: _________________ Status perkawinan : _________________
4. Pekerjaan : _________________ Pekerjaan : _________________
5. Pendidikan Terakhir: _______________ Pendidikan terakhir : _________________

Riwayat Kehamilan dan persalinan Yang Lalu

No Tahun Tipe Penolong Jenis BB Keadaan Masalah

Persalinan Kelamin lahir Bayi Waktu Kehamilan
Lahir
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Pengalaman menyusui : ya / tidak Lamanya : _________________

Riwayat Kehamilan Saat ini

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Beberapa Kali Periksa Hamil:
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 Masalah Kehamilan:
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Riwayat Persalinan
1. Jenis Persalinan : Spontan ( letkep/letsu)/Tindakan ( EF/EV )____________________
SC a/I __________________________Tgl/ jam ______________________________
2. Jenis Kelamin Bayi: L/P, BB/PB: _____ Gram/_____cm, A/S ___________________
Perdarahan ________cc
Masalah dalam Persalinan
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Riwayat Ginekologi :
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Masalah Ginekologi :
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Riwayat KB :
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II. Data Umum Kesehatan Saat Ini
Status Obstetrik: NH ____ P ____ A _____
Keluahan Utama :
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 Riwayat Keluhan Utama :
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Status Kesehatan Saat Ini :
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Bayi Rawat Gabung: ya/tidak
Jika tidak alasannya
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Keadaan umum: _________________________ Kesadaran: _______________________
BB :______kg
TB: ______ cm
Tanda Vital
Tekanan Darah : ____________mmHg
Frekuensi Nadi : ____________x/menit
Suhu : ____________ºC
Frekuensi Pernafasan : ____________ x/menit

Pemeriksaan Head To Toe:

Kepala :
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Mata :
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Hidung :
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Mulut :
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Telinga :
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Leher :
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Dada :
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Jantung :
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Paru :
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Payudara :
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Puting Susu :
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Penyaluran ASI:
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Abdomen (Involusi Uterus)
Fundus uterus:________________ Kontraksi: ______________ Posisi: _________________
Kandung Kemih
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Perineum dan genital
Vagina: ___________________________________________________________________
Integritas kulit ______________________________________________________________
Edema ____________________________________________________________________
Memar ____________________________________________________________________
Hematom __________________________________________________________________
Perineum: Utuh/Episiotomi/Ruptur Tanda REEDA:
R : Kemerahan: ya / tidak
E : Bengkak : ya / tidak
 E : echimosis : ya / tidak
D : discharge : serum/pus/darah/tidak ada
A : approximate : baik / tidak
Kebersihan : ____________________________________________________
Lochea :________________________________________________________
Jumlah:________________________________________________________
Jenis warna:_____________________________________________________
Konsistensi:_____________________________________________________
Bau:___________________________________________________________
Hemorrhoid : derajat : __________________ Lokasi ; __________________
Berapa lama ______________________________________ nyeri : ya / tidak
Ekstremitas
Ekstremitas atas : edema : ya / tidak, rasa kesemutan/baal : ya/tidak
Ekstremitas bawah : edema : ya / tidak, lokasi ________________________________
Varises : ya / tidak, lokasi ________________________________________________
Tanda Homan : +/-
Eliminasi
Urin : Kebiasaan BAK _________________________________________________
BAK saat ini ______________________________________ nyeri : ya / tidak
BAB : Kebiasaan BAB _________________________________________________
BAB saat ini ____________________________________ Kontipasi : ya/tidak
Istirahat dan Kenyamanan
Pola tidur : kebiasaan tidur, lama _____ jam, frekuensi ________________________
Pola tidur saat ini ______________________________________________________
Keluhan ketidaknyamanan: ya / tidak, lokasi
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Sifat _____________________________________________________________________
Insentitas _________________________________________________________________
Mobilisasi dan latihan
Tingkat mobilisasi : ____________________________________________________
Latihan/senam : ______________________________________________________
 Nutrisi dan Cairan
Asupan Nutrisi : ____________________________________________________________
Nafsu makan: baik/kurang/tidak ada
Asupan cairan : ________________________________________________ cukup / kurang
Keadaan Mental
Adaptasi psikologis :
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Penerimaan terhadap bayi :
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Kemampuan menyusui :
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Obat-obatan:
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Hasil Pemeriksaan Penunjang:
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Perencanaan Pulang (discharge Planning) :
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KLASIFIKASI/PENGELOMPOKKAN DATA BERDASARKAN GANGGUAN
KEBUTUHAN
1. Keluhan (Data Subjektif)
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2. Data objektif
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ANALISA DATA BERDASARKAN PATOFISIOLOGI DAN PENYIMPANGAN KDM

Penyakit (Diagnsa Medis) Klien :

Respon utama :

Penyimpangan KDM : (Bagan Sistematis)

RUMUSAN DIAGNOSA KEPERAWATAN

(Rujukan Diagnosa SDKI)

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