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 ____________________________

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 _____________________________________
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 : ________________________________________________________
Penerimaan terhadap bayi : ___________________________________________________
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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