KEPERAWATAN MATERNITAS

FORMAT PENGKAJIAN POST PARTUM

Nama Mahasiswa :_________________

Nim : _________________

Tanggal Masuk : ………....................... Jam Masuk : …………………….

Ruang/Kelas : ................................... No.Kamar : .................................
Tgl.Pengkajian : ................................... Jam : .................................
I. Identitas :
Nama Pasien : ................................... Nama Suami : ................................
Umur :.................................... Umur : .................................
Suku/Bangsa : ................................... Suku Bangsa : .................................
Agama : .................................. Agama : .................................
Pendidikan : .................................. Pendidikan : .................................
Pekerjaan : .................................. Pekerjaan : .................................
Alamat : .................................. Alamat : .................................
.................................................................. ...........................................................
Status Perkawinan : ................................. Lama perkawinan : .............. tahun
Kawin : .............. kali
II. Riwayat Keperawatan
A. Keluhan utama (saat masuk RS) :
..................................................................................................................................................................
............................................................................................................
B. Riwayat Menstruasi
1. HPHT : ..................................................
2. Tapsiran Persalinan : ...................................................
C. Riwayat Persalinan Sekarang
1. Tanggal persalinan : ................................. Jam : .....................................
2. Tipe persalinan : spontan / buatan : .........................................................
3. Lama Persalinan : Kala I : .................. jam
Kala II : .................. jam .................. menit
Kala III : .................. menit
Jumlah : ................. Jam ................. menit
4. Jumlah perdarahan : ................. ml
5. Jenis kelamin bayi : BB : ........kg PB : ......... cm
6. APGAR Score : menit I ................ Menit II : ..............................
D. Riwayat Obsetri :
Kehamilan Persalinan Komplikasi Anak
Anak Umur Penyulit Jenis Penolong penyulit Nifas Jenis BB PB Keadaan
ke Kehamilan Umur
sekarang

E. Riwayat Keluarga Berencana (KB)

- Melaksanakan KB ya tidak
- Bila ya, jenis kontrasepsi apa yang digunakan : IUD PIL Suntik
Implant lain-lain : rebutkan : ..........................................
- Sejak kapan menggunakan kontrasepsi : ...............................................
- Masalah yang terjadi : ...........................................................................
- Rencana yang akan datang : ..................................................................
F. Riwayat Imunisasi TT : ya/tidak : bila ya, berapa kali berikan selama hamil : ......x
Usia kehamilan pemberian imunisasi : .....................................................................
G. Riwayat Penyakit Lalu : ............................................................................................
...................................................................................................................................

F.Pengkajian-Maternitas-Akper-Lakipadada-2008 1
 H. Riwayat Penyakit Keluarga
Diabetes mellitus
Jantung
Hipertensi
Lain-lain, sebutkan : ........................................................................................

I. Kebiasaan Sehari-hari
1. Pola Nutrisi/Cairan
Subjektif :
 Frekuensi makan : ............... x / hari
 Jenis makanan : .................................................................................
 Nafsu makan : baik tidak
 Mual/muntah : .................................................................................
 Keluhan diperut : .................................................................................
 Alergi/toleransi makanan : ............................................................................
 Masalah mengunyah/menelan : ....................................................................
 Pantangan makanan : .................................................................................
Objektif
 BB saat ini : ............... kg TB : ............... cm
 Bentuk tubuh : .................... Turgoor kulit : .......................
 Membran mukosa : .................................................................................
 Edema : .................................................................................
 Bau mulut : .................................................................................
 Kondisi gigi/gusi : .................................................................................
 HB/HT : .................................................................................
2. Eliminasi
Subjektif :
a. BAB
 Frekuensi : ......... x / heri
 Karakteristik feces : ............defekasi terakhir : ...........................
 Hemoroid : .....................................................................
 Diare : .................... Konstipasi : ...........................
 Penggunaan laksatif : .....................................................................
 Keluhan : .....................................................................
a. BAK
 Frekuensi : ......... x / heri
 Karakteristik urine : .....................................................................
 Keluhan : .....................................................................
 Terakhir berkemih : .....................................................................
 Riwayat penyakit ginjal/kandung kemih : ..............................................
 Adanya kateter : .....................................................................
Objektif :
 Palpasi abdomen : .....................................................................
 Bising usus : .....................................................................
 Hemoroid : .....................................................................
 Palpasi kandung kemih : .....................................................................
 Urinalisis : Albuminuria : .....................................................................
Glikosuria : .....................................................................
 Jumlah urin, karakteristik : .....................................................................
3. Personal Hygiene
Subjektif
a. Mandi
 Frekuensi : ............. x / hari
 Sabun : ya tidak
b. Oral hygiene
 Frekuensi : ............. x / hari
 Waktu : pagi makan setelah
makan

F.Pengkajian-Maternitas-Akper-Lakipadada-2008 2
 c. Rambut
 Frekuensi : ............. x / hari
 Shampo : ya tidak

Objektif :
 Penampilan umum : .........................................
 Cara berpakaian : .........................................
 Bau badan : .........................................
 Kondisi kulit kepala : .........................................
 Adanya kutu : .........................................

4. Aktivitas/Istirahat Tidur
Subjektif :
 Kegiatan dalam pekerjaan : .........................................................
 Hobby : .........................................................
 Kegiatan waktu luang : .........................................................

 Keluhan dalam beraktivitas : .........................................................

 Aktivitas kehidupan sehari-hari : mandiri tergantung
 Peralatan/alat protesis yg diperlukan : .........................................................
 Bantuan yang diberikan : .........................................................
 Lama tidur : .........................................................
 Tidur siang : .........................................................
 Keluhan/masalah tidur : .........................................................
Objektif :
 Massa/tonus otot : .....................................................................
 Tremor : .....................................................................
 Kekuatan : .....................................................................
 Deformitas : .....................................................................
 Lingkar hitam pada mata : .....................................................................
 Mata merah : .....................................................................
5. Pola Kebiasaan Yang Mempengaruhi Kesehatan :
a. Merokok :
 Frekuensi : ya tidak
 Jumlah : ...........................................
 Lama pemakaian : ...........................................
b. Minuman keras
 Frekuensi : ya tidak
 Jumlah : .......................................................
 Lama pemakaian : .......................................................
c. Ketergantungan obat
 Frekuensi : ya tidak
 Jumlah : ......................................................
 Lama pemakaian : ......................................................
 Alasan/keluhan : ......................................................
6. Pola Psikososial
Masalah seksual : ya / tidak, Bila Ya : .................................................................
J. Riwayat Psikososial
Subjektif :
 Pengalaman persalinan : .....................................................................................
 Kesiapan mental menjadi ibu : ...........................................................................
 Cara mengatasi stress : .......................................................................................
 Tinggal dengan : .................................................................................................
 Peran dalam dan struktur keluarga : ...................................................................
 Kesanggupan dan pengetahuan dalam merawat bayi : .......................................
 Faktor kebudayaan yang mempengaruhi kesehatan ...........................................
.............................................................................................................................

F.Pengkajian-Maternitas-Akper-Lakipadada-2008 3
 Objektif :
 Status emosional : ...............................................................................................
 Respon psikologis yang diamati : .......................................................................
 Komunikasi verbal/non verbal dengan orang terdekat/keluarga : ......................
..............................................................................................................................
 Perilaku pola interaksi keluarga : ........................................................................
K. Status Sosial Ekomoni
Masalah finansial : .....................................................................................................

L. Sirkulasi/Sistem Kardivaskuler
Subjektif :
 Riwayat peningkatan TD : ...................................................................................
 Ekstremitas mati rasa : ....................... Kesemutan : .....................................
 Masalah jantung : ...................................................................................
Objektif :
 TD : ................. Nadi : ..................... Suhu : ..................
 Pengisian kapiler : ..................................................................................
 Tanda hormon : ..................................................................................
 Varises : ..................................................................................
 Konjungtiva : .................... Sklera : ................. Diaforesis : ........................
M. Neurosensorik
Subjektif :
 Serangan pinhgsan/pusing : ya tidak
 Sakit kepala : ya tidak
 Kesemutan/kebas/kelemahan : ya tidak
 Kejang : .........................................
 Mata : ......................... Telingan : ................. Penciuman : .................
Objektif :
 Status mental : berorientasi/disorientasi
 Kaca mata : ya tidak
 Alat bantu tangan : ya tidak
N. Pernapasan
Subjektif :
 Batuk sputum : ...................................................................................
 Riwayat bronchitis : ................................... Asma : ...................................
 TBC : ................................... Pneumonia : ...........................
 Penggunaan alat bantu pernapasan : ......................................................................
Objektif :
 Frekuensi pernapasan : ....................................
 Bunyi napas : ....................................
 Karakteristik sputum : ....................................
 Hasil rongga dada : ....................................
O. Nyeri/Ketidaknyamanan
Subjektif :
 Lokasi nyeri : ..................................... Intensitas : ........................................
 Kualitas : ..................................... Durasi : ........................................
 Faktor pencetus : ..................................... Bagaimana hilangnya : .....................
Objektif :
 Wajah : ..................................................
 Respon emosional : ..................................................
P. Dada dan axila
 Mammae membesar : ya tidak
 Areola mammae : ...............................................
 Papila mammae : inverted/daftar/exverted
 Kolostrum keluar : ya tidak
 Pemberian asi : ya tidak : ..................... jam setelah lahir

F.Pengkajian-Maternitas-Akper-Lakipadada-2008 4
 Q. Abdomen
 Tinggi nfundus uteri : ........................................
 Kontraksi : ........................................
 Konsistensi uterus : ........................................
 Luka : ........................................
 Tanda bekas operasi : ........................................
 Diastasis abdominalis : Panjang : ................... cm
Lebar : ................... cm
R. Anogenital :
 Lochea : ....................................... Haemoroid.
 Warna : .......................................
 Banyaknyanjumlahnya : .......................................
 Laserasi : .......................................
 Apisiotomi : ....................................... Jenis : .......................................
 Tanda : .......................................

III. Pemeriksaan Penunjang

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IV. Penatalaksanaan
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V. Resume
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