FORMAT PENGKAJIAN POSTPARTUM

MAHASISWA PROGRAM STUDI KEPERAWATAN & NERS

UNIVERSITAS MANDALA WALUYA KENDARI

Tanggal masuk RS :...............................................................

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

I. BIODATA
A. Identitas Istri/ibu
a. Nama :...........................................................................
b. Umur :...........................................................................
c. Suku/bangsa:................................../...............................
d. Agama :................................./................................
e. Pend.trakhir :................................./................................
f. Pekerjaan :................................./................................
g. Penghasilan/Bln :..................................................................
h. Status Perkawinan:..................................................................
i. Lamanya :....................................................................
j. Perkawinan yang ke:......................................................................
k. Alamat:...........................................................................................
l. Tanggal Kunjungan:.......................................................................

B. Identitas Suami
a. Nama :...................................................................................
b. Umur:............................................................................................
c. Suku/Bangsa:...............................................................................
d. Agama :........................................................................................
e. Pend.trakhir :................................./................................
f. Pekerjaan :................................./................................
g. Penghasilan/Bln :..................................................................
h. Status Perkawinan:..................................................................
i. Lamanya :....................................................................
j. Perkawinan yang ke:......................................................................
k. Alamat:...........................................................................................
II. DATA BIOLOGIS/FISIOLOGIS
1. Keluhan Utama (mual/muntah,pusing/sakit kepala, keluar darah dll)
:.........................................................................................................
..........................................................................................................
2. Riwayat Keluhan utama :...................................................................
a. Mulai Timbulnya..........................................................................
b. Sifat Keluhan ( Kualitas/Kuantitas).............................................
 c. Lokasi Keluhan............................................................................
d. Faktor Pencetus..........................................................................
e. Keluhan Lain...............................................................................
f. Pengaruh Keluhan terhadap aktifitas/Fungsi tubuh...................
g. Usaha Klien untuk mengatasi keluhan.......................................
h. Efektifitas tindakan yang di lakukan...........................................
3. Riwayat kesehatan masa Lalu
a. Penyakit yang pernah di derita...................................................
b. Riwayat opname ( kapan/alasan)...............................................
c. Riwayat Trauma (kapan/alasan).................................................
d. Riwayat operasi (kapan/alasan)....................................................
e. Riwayat transfusi darah (kapan,alasan , reaksi )..........................
4. Riwayat Kehamilan dan Persalinan serta nifas yang lalu
Anak pertama
No Kehamilan Persalinan Anak Riwayat
Umur Keadaan Thn Tempat Penolong Jenis P/L Lamanya Keadaan Nifas
Menyusui sekarang

Anak kedua

No Kehamilan Persalinan Anak Riwayat

Umur Keadaan Thn Tempat Penolong Jenis P/L Lamanya Keadaan Nifas
Menyusui sekarang

5. Riwayat kehamilan terakhir

a. Rravida :...............Para :...............Abortus :..........................
b. Haid Terakhir :.....................................Tafsiran persalinan :...........
c. Penyulit kehamilan..........................................................................
d. Imunisasi TT...................................................................................
6. Pola Reproduksi
a. Menarche umur :......................................................................
b. Siklus Haid :......................................................................
c. Lamanya Haid :......................................................................
d. Sifat Darah :......................................................................
e. Dismenorhea :......................................................................
7. Riwayat Pola kegiatan Sehari-hari
a. Nutrisi
1) Jenis Makanan....................................................
2) Frekuensi makan sehari.....................................
3) Nafsu Makan......................................................
4) Makanan Pantang..............................................
5) Makanan Kesukaan...........................................
 6) Banyaknya Minum Sehari..................................
b. Eliminasi
Kebiasaan:
1) Frekuensi BAK :.........................................................
2) Warna/bau Khas :......................................................
3) Gangguan Eliminasi (BAK);.......................................
4) Frekuensi BAB:..........................................................
5) Warna/Konsistensi BAB:...........................................
c. Kebutuhan kebersihan diri sendiri
Kebiasaan:
1) Kebersihan Rambut:................................................
2) Kebersihan Badan:..................................................
3) Kebersihan gigi/mulut :............................................
4) Kebersihan Genitalia dan Anus:..............................
5) Kebersihan Kuku tangan/kaki:.................................
6) Kebersihan pakaian:................................................
Perubahan Selama Hamil.........................................................

d. Kebutuhan Rekreasi/olahraga :
Kebiasaan :
1) Jenis/frekuensi rekreasi :.....................................................
2) Jenis/frekuensi olahraga :....................................................
3) Jenis rekreasi/olahraga :......................................................
Perubahan Selama Hamil:........................................................

e. Kebutuhan istirahat /tidur :

Kebiasaan :
1) Istirahat / tidur siang:............................................................
2) Istirahat/Tidur malam:..........................................................
3) Pekerjaan RT di lakukan :...................................................
4) Merawat anak di lakukan :...................................................
Selama Hamil :

1) Perubahan :.........................................................................
2) Peranan Keluargadalam membantuibu istirahat:................
f. Kebutuhan Seksual ( Bila Mungkin/perlu)
1) Kebiasaan :.........................................................................
2) Perubahan Selama Hamil:..................................................
8. Pemeriksaan Fisik
a. Pemeriksaan Fisik Umum:
1) Penampilan Ibu :.................................................................
2) Kesadaran:..........................................................................
3) Tinggi/BB:........................Cm/..........................................Kg

4) Tanda Vital :
 a) Tekanan Darah:............................mmHg
b) Nadi:............................................./menit
c) Suhu:.............................................0C
d) RR:.............................................../Menit
5) Inspeksi Kepala dan Rambut :
a) Keadaan Rambut:......................................................
b) Kebersihan Rambut:..................................................
6) Inspeksi Wajah/Muka
a) Edema Wajah/Muka :...............................................
b) Ekspresi Wajah:........................................................
7) Mata
a) Kebersihan:..............................................................
b) Konjungtiva:............................................................
c) Sklera:.....................................................................
d) Kelopak Mata:.........................................................
8) Inspeksi Hidung
a) Kesimetrisan :.........................................................
b) Sekret Hidung:........................................................
c) Epistaksis:..............................................................
9) Inspeksi gigi dan Hidung :
a) Kebersihan gigi/mulut:............................................
b) Keadaan Gigi:.........................................................
c) Keadaan Gusi........................................................
d) Keadaan Lidah.......................................................
e) Keadaan Mukosa bibir...........................................
f) Caries/Protese:......................................................
10) Inspeksi Telinga
a) Kebersihan Telinga...............................................
b) Sekret Telinga.......................................................
c) Keadaan Telinga Luar...........................................
11) Inspeksi /palpasi leher :
a) Pembesaran Kelenjar gondok:.............................
b) Pembesaran Vena Jugularis:...............................
c) Pembesaran Arteri Karotis:..................................
12) Inspeksi /Palpasi dan Auskultasi dada/perut :
a) Payudara :
 Kesimetrisan:...............................
 Keadaan Puting:..........................
 Keadaan Areola:..........................
 Kolostrum:...................................
b) Jantung :
 Ictus Cordis:............................................
 Bunyi Tambahan:....................................
 c) Paru :
 Bunyi Pernafasan:..................................
 Bunyi Tambahan:...................................
d) Abdomen
 Keadaan abdomen...............................
 Posisi....................................................
 TFU......................................................
e) Vulva
 Luka perineum :.......................berapa jahitan...........
 Apakah ada Udema:.....................................................
 Apakah ada Varises :....................................................
 Apabila di lakukan Episiotomi :.....................................
 Jenis episiotomi :.................panjangnya :.....................
 Apakah ada Tanda-tanda Infeksi :................................
f) Lochia
 Warna/Jenis :.........................................................
 Banyaknya :.........................................................
 Baunya :.........................................................

III. PEMERIKSAAN PENUNJANG

Pemeriksaan Laboratorium
NAMA PEMERIKSAAN Hasil Nilai Normal
Lekosit 7.72 ribu/uL 3.60 – 11.0
Eritrosit 4.31 juta/uL 3.80 – 5.20
Hemoglobin 12.76 g/dL 11.7 – 15.5
RDW-CV 12.3 % 11.5 – 14.5
Trombosit 240 ribu/uL 150 – 440
MPV 7.077 fL 7.2 – 11.1
Hematokrit 36.1 % 35 – 47
Basofil 0.53 % 0-1
Limfosit 15.53 % 25 – 40
Eosinofil 1.29 % 2–4
Monosit 5.84 % 2– 8
Neutrofil 76.81 % 39/3 – 73.7
MCV 83.9 fL 80 – 100
MCH 29.6 pg 26.0 – 34.0
MCHC 35.3 % 32 – 36
MCV 83.9 fL 80 – 100
PPT 13.3 detik 11.8 – 15.1
KPTT 28.2 detik 25.0 – 38.4