POST PARTUM

NORMAL
Di Susun Untuk Memenuhi Tugas Mata Kuliah Keperawatan Maternitas
Dengan Dosen Pengampu Ibu :
Hj. Melly,SST., M. Kes
 Disusun Oleh :
Kelompok 3 (2A)

Mila Rahmwati (032014401021)

Maizatul Azamiyah (032014401019)
Nabillah Athaviardi (032014401024)
Nadia Rahmadhani (032014401025)
Novia Yulia Windri (032014401027)
Rima Mauliddiana (032014401034)
Septiani Musdalifah (032014401035)
Suci Rahmayati (032014401037)
Tasya Iqrammullah (032014401038)
Tiara Pratiwi (032014401039)
Putri Azkia (032014401030)
Yuliani (032014401042)
01 KONSEP DASAR POST PARTUM
NORMAL

02 KONSEP DASAR ASUHAN

KEPERAWATAN POST PARTUM NORMAL
 KONSEP DASAR
ASUHAN KEPERAWATAN
 1. PENGKAJIAN
a. Pengkajian data dasar klien

meliputi observasi, wawancara, pemeriksaan fisik.

b. Indentitas klien

1) Indentitas klien, meliputi : nama, usia, status perkawinan, pekerjaan, agama,

 
pendidika, suku, bahasa yang digunakan, sumber biaya, tanggal masuk rumah
sakit dan jam, alamat rumah.
2) Indentitas suami, meliputi : nama suami, umur, pekerjaan, agama, pendidikan,
suku.
c. Riwayat Keperawatan

• Riwayat Kesehatan > Data yang perlu dikaji antara lain : keluhan utama saat masuk RS
• Riwayat Kehamilan > Informasi yang dibutuhkan adala para dan gravida, kehamilan yang direncanakan
• Riwayat melahirkan >Data yang harus dikaji adalah tanggal melahirkan, lamanya persalinan, posisi fetus, tipe
melahirkan, analgetik, masalah selama melahirkan, jahitan pada perineum dan perdarahan.
• Data Bayi > Data bayi yang harus dikaji meliputi jenis kelamin, dan berat badan bayi.
LANJUTAN…
• Pengkajian masa post partum atau post partum pengkajian yang dilakukan
meliputi keadaan umum.

d. Pemeriksaan Fisik

1) Rambut Mengkaji kekuatan rambut klien karena diet yang baik selama masa hamil akan
berpengaruh pada kekuatan dan kesehatan rambut.
2) Muka Mengkaji adanya edema pada muka yang dimanifestasikan dengan kelopak maya yang
bengkak atau lipatan kelopak mata bawah menonjol.
3) Mata Mengkaji warna konjungtiva bila bewarna merah dan basah berarti normal, sedangkan pucat
berarti ibu berarti ibu mengalami anemia, dan jika kongjutiva kering maka ibu mengalami dehidrasi.
4) Payudara Mengkaji pembesaran, ukuran, bentuk, konsistensi, warna payudara dan mengkaji kondisi
punting, kebersihan punting.

5) Lochea Mengkaji lochea yang meliputi karakter, jumlah, warna, bekuan darah yang dikeluarkan dan
baunya.
6) Sistem perkemihan Mengkaji kandung kemih dengan palpasi dan perkusi
LANJUTAN…
7. Perineum Pengkajian dilakukan dengan menempatkan ibu pada posisi senyaman mungkin dan
tetap menjaga privasi dengan inpesksi tanda-tanda “REEDA”

8. Extermitas bawah dan atas Extermitas atas dan bawah dapat bergerak bebas, kadang
ditemukan edema, varises pada tungkai kaki, ada atau tidaknya tromboflebitis karena
penurunan aktivitas dan reflek patela baik.

e. Tanda – Tanda Vital

Mengkaji tanda-tanda vital meliputu suhu, nadi, pernapasan, dan tekanan darah selama 24 jam pertama masa
post partum.
f. Pemeriksaan Penunjang
1) Jumlah darah lenkap Hemoglobin dan Hemaktokrit (Hb atau Ht) : mengkaji perubahan dari kadar darah
pra operasi dan mengevaluasi efek dari kehilangan darah.
2) Urinalisis : kultur urine, darah, vaginal dan lochea, pemeriksaan tambhan adidasarkan kebutuhan individual.
 2. DIAGNOSA

Nyeri aku berhubungan dengan agen

pencidera fisik (luka post partum). Gangguan Pola Tidur berhubungan dengan
kontrol tidur

Ketidaknyamanan pasca partum

Defisit Pengetahuan berhubungan denan kurang
berhubungan dengan trauma perinium
terpapar informasi.
selama persalinan dan kelahiran.

Resiko Gangguan Perlekatan berhubungan

Menyusui Tidak Efektif berhubungan dengan kekhawatiran menjalankan peran
dengan ketidakadekuatan suplai Asi, sebagai seorang ibu.
tidak rawat gabung.

Resiko infeksi berhubungan dengan efek

prosedur invasif.
 3. INTERVENSI

No Diagnosa Kriteria Hasil Intervensi

1. Nyeri aku berhubungan Setelah dilakukan intervensi Observasi

dengan agen pencidera fisik
(luka post partum).
keperawatan selama 1 x 24 jam
diharapkan tingkat nyeri menurun 1. Identifikasi lokasi, karakteristik, durasi, frekuensi, intensitas nyeri.
dengan Kriteria hasil : 2. Identifikasi skala nyeri.
1. Pasien melaporkan keluhan nyeri 3. Identifikasi faktor yang memperberat dan memperingan nyeri.
berkurang 4. Identifikasi pengetahuan dan keyakinan tentang nyeri
2. Keluhan nyeri meringis menurun 5. Monitor keberhasilan terapi komplementer yang sudah diberikan.
3. Pasien menunjukkan sikap
protektif menurun. Terapeutik
4. Pasien tidak tampak gelisah.
6. Berikan tehnik norfarmakologis untuk mengurangi rasa nyeri
7. Fasilitasi istirahat dan tidur

Edukasi

8. Jelaskan penyebab, periode dan pemicu nyeri.

9. Jelaskan strategi meredakan nyeri
10. Anjurkan memonitor nyeri secara mandiri.
11. Ajarkan tehnik nonfarmakologis untuk mengutangi nyeri.

Kolaborasi Kolaborasi pemberian analgetik, jika perlu

No Diagnosa Kriteria Hasil Intervensi Rasional

2. Menyusui Tidak Efektif Setelah dilakukan intervensi Observasi

berhubungan dengan keperawatan selama 1 x 24
ketidakadekuatan suplai jam diharapkan status 1. Identifikasi permasalahan yang ibu alami selama proses
Asi, tidak rawat menyusui membaik dengan menyusui.
gabung. kriteria hasil : 2. Identifikasi keinginan dan tujuan menyusui.
1. Perlekatan bayi pada 3. Identifikasi keadaan emosional ibu saat akan dilakukan
payudara ibu meningkat. konseling menyusui
2. Kemampuan ibu
memposisikan bayi Terapeutik
dengan benar meningkat.
3. Pancaran ASI meningkat 4. Gunakan tehnik mendengar aktif.
4. Suplai ASI adekuat 5. Berikan pujian terhadap perilaku ibu yang benar.
meningkat.
5. Pasien melaporkan Edukasi
payudara tidak bengkak
Ajarkan tehnik menyusui yang tepat sesuai kebutuhan ibu
 

3. Gangguan Pola Tidur Setelah dilakukan intervensi Observasi

berhubungan dengan keperawatan selama 1 x 24
kontrol tidur jam diharapkan status pola 1. Identifikasi lokasi, karakteristik, durasi, frekuensi,
tidur membaik dengan intensitas nyeri.
2. Identifikasi skala nyeri.
kriteria hasil :
3. Identifikasi faktor yang memperberat dan memperingan
1. Gelisah menurun
nyeri.
2. Keluhan sulit tidur
4. Identifikasi pengetahuan dan keyakinan tentang nyeri
menurun
5. Monitor keberhasilan terapi komplementer yang sudah
3. Pola tidur membaik
diberikan.

Terapeutik

Berikan tehnik norfarmakologis untuk mengurangi rasa nyeri

Fasilitasi istirahat dan tidur
No Diagnosa Kriteria Hasil Intervensi Rasional
Edukasi

1. Jelaskan penyebab, periode dan pemicu nyeri.

2. Jelaskan strategi meredakan nyeri
3. Anjurkan memonitor nyeri secara mandiri.
4. Ajarkan tehnik nonfarmakologis untuk
mengutangi nyeri.

Kolaborasi Kolaborasi pemberian analgetik, jika perlu

4. Defisit Pengetahuan Setelah dilakukan intervensi Observasi

berhubungan denan kurang keperawatan selama 1 x 24 jam
terpapar informasi. diharapkan status pengetahuan 1. Identifikasi kesiapan dan kemampuan menerima
meningkat dengan kriteria hasil: informasi
1. perilaku sesuai anjuran 2. Identifikasi faktor-faktor yang dapat meningkatkan
meningkat dan menurunkan motivasi perilaku hidup bersih
2. verbalisasi minat dalam belajar dan sehat
meningkat
3. kemampuan menjelaskan Terapeutik
pengetahuan tentang suatu
topik meningkat 3. Sediakan materi dan medla pendidikan
4. kemampuan menggambarkan kesehatan
pengalaman sebelumnya yang 4. Jadwalkan pendidikan kesehatan sosial
sesuai dengan topik meningkat kesepakatan
5. perilaku sesuai dengan 5. Berikan kesempatan untuk bertanya
pengetahuan meningkat
6. pertanyaan tentang masalah Edukasi
yang dihadapi menurun
7. persepsi yang keliru terhadap 6. Jelaskan faktor risiko yang dapat mempengaruhi
masalah menurun kesehatan
8. menjalani pemeriksaan yang 7. Ajarkan perilaku hidup bersih dan sehat
tidak tepat menurun 8. Ajarkan strategi yang dapat digunakan untuk
9. perilaku membaik meningkatkan perilaku hidup bersih dan sehat
No Diagnosa Kriteria Hasil Intervensi Rasional

5. Resiko Setelah dilakukan intervensi keperawatan Observasi

infeksi dalam kurun waktu tertentu diharapkan Monitor tanda dan gejalan infeksi lokal dan sistemik.
berhubungan tingkat Infeksi menurun dengan kriteria
dengan efek hasil : Terapeutik
prosedur 1. Tidak ada tandan –tanda infeksi 1. Cuci tangan sebelum dan sesudah kontak dengan pasien dan
invasif. (Demam, Nyeri, Kemerahan dan lingkungan pasien.
Bengkak). 2. Pertahankan tehnik aseptik pada psien beresiko tinggi.
2. Kadar sel darah putih membaik.
3. Intervensi Pencegahan Infeksi Edukasi
3. Jelaskan tanda dan gejala infeksi
4. Ajarkan cara mencuci tangan dengan benar.
5. Ajarkan cara memeriksa kondisi luka.
6. Anjurkan meningkatkan asupan nutrisi.

6. Resiko Setelah dilakukan intervensi keperawatan Observasi

Gangguan dalam kurun waktu tertentu diharapkan 1. Monitor kegiatan menyusui.
Perlekatan tingkat kemampuan berinteraksi ibu dan 2. Identifikasi kemampuan bayi menghisap dan menelan ASI.
berhubungan bayi meningkat dengan kriteria hasil : 3. Identifikasi payudara ibu.
dengan 1. Pasien menunjukkan peningkatan 4. Monitor perlekatan saat menyusui
kekhawatiran verbalisasi perasaan positif
menjalankan terhadap bayi. Terapeutik
peran sebagai 2. Pasien menunjukkan peningkatan Diskusikan dengan ibu masalah selama proses menyusui.
seorang ibu. perilaku mencium bayi, tersenyum
pada bayi, melakukan kontak mata Edukasi
dengan bayi, berbicara dengan bayi,
berbicara kepada bayi serta 5. Ajarkan ibu menopang seluruh tubuh bayi.
berespon dengan isyarat bayi. 6. Anjurkan ibu melepas pakaian bagian atas agar bayi dapat
3. Pasien menunjukkan peningkatan menyentuh payudara ibu.
dalam menggendong bayinya untuk 7. Ajarkan ibu agar bayi yang mendekati kearah payudara ibu dari
menyusui. bagian bawah.
8. Anjurkan ibu untuk memegang payudara menggunakan jarinya
sepertu huruf “ C”. 51
9. Anjurkan ibu untuk menyusui pada saat mulut bayi terbuka lebar
sehingga areola dapat masuk dengan sempurna.
10. Ajarkan ibu mengenali tanda bayi siap menyusui.
 4. IMPLEMENTASI

Implementasi keperawatan adalah serangkaian kegiatan yang dilakukan oleh perawat untuk
membantu klien dari masalah status kesehatanyang dihadapi ke status kesehatan yang lebih baik yang
menggambarkan kriteria hasil yang diharapkan (Potter, 2011)

Komponen tahap implementasi :

a) Tindakan keperawatan mandiri.

b) Tindakan Keperawatan edukatif.

c) Tindakan keperawatan kolaboratif.

d) Dokumentasi tindakan keperawatan dan respon klien terhadap asuhan keperawatan.

 5. EVALUASI
a. Evaluasi mengacu kepada penilaian, tahapan, dan perbaikan

1 2 3 4 5

Perawat Bagaimana reaksi klien Menetapkan kembali Kemampuan dalam

Menentukan target dari
menemukan terhadap intervensi yang informasi baru yang pengetahuan standar asuhan
suatu hasil yang ingin
penyebab mengapa telah diberikan dan diberikan kepada keperawatan, respon klien
dicapai adalah
suatu proses menetapkan apa yang klien untuk yang normal terhadap
keputusan bersama
keperawatan dapat menjadi sasaran dari mengganti atau tindakan keperawatan dan
antara perawat dan
berhasil atau gagal. rencana keperawatan menghapus diagnosa Evaluasi berfokus pada
klien (Yura & Walsh,
(AlfaroLeFevre, dapat diterima. keperawatan, tujuan, individu klien dan
1988)
1994) atau intervensi kelompok dari klien itu
keperawatan sendiri
.
.
Lanjutan…
b. Evaluasi 2 Komponen
 Formatif
o Tiap selesai melaksanakan tindakan
keperawatan
o Evaluasi proses, biasanya berupa
catatan perkembangan
 Sumatif
o Rekapan terakhir secara paripurna
o Catatan naratif Penderita pulang /
pindah
c. Evaluasi dengan pedekatan SOAP
 Subyek
 Obyek
 Analisa adalah ulang respon s dan o (assesment)
o Masalah belum teratasi
o Teratasi sebagian
o Muncul masalah baru
o Teratasi
 Planning
o Rencana diteruskan
o Dimodifikasi
o Dibatalkan ada masalah baru
o Selesai (tujuan tercapai)
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Get a modern PowerPoint
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 Example Text : Get a modern
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THANK YOU
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You can Resize without

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You can Change Fill
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 Fully Editable Icon Sets: C

You can Resize without

losing quality
You can Change Fill
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