format pengkajian post natal
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Pengkajian Post Natal
ASUHAN KEPERAWATAN PADA Ny……
DENGAN ……………………………………………………………..
Di RUANG ……………………………………
TANGGAL ………………………….
A. PENGKAJIAN
I. IDENTITAS PASIEN
Nama : ........................................
Umur : ........................................
Pendidikan : ........................................
Pekerjaan : ........................................
Status perkawinan : .......................................
Agama : .......................................
Suku : .......................................
Alamat : .......................................
No. CM : .......................................
Tanggal MRS : ........................................
Tanggal pengkajian: ........................................
Sumber Informasi : ........................................
Diagnosa masuk : ........................................
II. PENANGGUNG/ SUAMI
Nama : ........................................
Umur : ........................................
Pendidikan : ........................................
Pekerjaan : ........................................
Alamat : ........................................
Hubungan dengan pasien : ........................................
III. RIWAYAT PENYAKIT
Keluhan utama (saat MRS dan sekarang)
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Riwayat Penyakit Sekarang
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IV. RIWAYAT OBSTETRI DAN GINEKOLOGI
1. Riwayat Menstruasi :
Menarche : umur ................. Siklus : teratur ( ) tidak ( )
Banyaknya : ........................... Lamanya : ..............................
Keluhan : ...........................
2. Riwayat Pernikahan :
Menikah : ................. kali Lama : ............... tahun
3. Riwayat kehamilan, persalinan, nifas yang lalu :
Anak ke Kehamilan Persalinan Komplikasi Nifas Anak
No TahunUmur
KehamilanPenyulit Jenis Penolong Penyulit
Laseras
iInfeksi Perdarahan JK BB Pj
4. Riwayat Keluarga Berencana :
Akseptor KB : jenis ..................... Lama : .........................
Masalah : .............................
5. Riwayat Penyakit Klien dan Keluarga
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V. POLA FUNGSIONAL KESEHATAN
a. Pemeliharaan dan persepsi terhadap kesehatan
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b. Nutrisi/ metabolic
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c. Pola eliminasi
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d. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total
Keterangan :
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e. Pola tidur dan istirahat
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f. Pola perseptual
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g. Pola persepsi diri
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h. Pola seksual dan reproduksi
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i. Pola peran-hubungan
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j. Pola manajemen koping stress
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k. Sistem nilai dan keyakinan
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V. PEMERIKSAAN FISIK
Keadaan Umum
GCS : .......................................................................................
Tingkat Kesadaran : .......................................................................................
Tanda-tanda vital : TD ............... N ................. RR ................ T................
BB : ..................... TB ................ LILA : ......................
Head to toe
Kepala :
Wajah :
Mata :
Leher :
Dada :
Payudara Inspeksi :
Areola ................. Puting : (menonjol/tidak)
Tanda dimpling/retraksi : ....................................
Palpasi : Pengeluaran ASI ......................
Adanya nodul : ...........................
Jantung dan Paru :
Inspeksi: ....................................................................................................................
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Palpasi: ......................................................................................................................
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Perkusi: .....................................................................................................................
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Auskultasi: .................................................................................................................
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Abdomen :
Inspeksi : Linea : .................. Striae : ...............
Luka SC : .......................
Auskultasi : Bising usus : …………………………….
Palpasi :
TFU : …………………………….
Kontraksi : ……………………………
Diastasis rectus abdominis : …………………………….
Perkusi
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Genetalia dan Perineum :
Kebersihan : ......................................................................................
Lokhea : ......................................................................................
Perineum : REEDA ........................................................................
Karakteristik : .......................................................................................
Anus :
Haemorroid : ........................................................................................
Ekstremitas bawah
Oedema :
Varises :
CRT :
Kekuatan otot :
Tonus :
Ekstremitas atas
Oedema :
Varises :
CRT :
Kekuatan otot :
Tonus :
VI. DATA PENUNJANG
a. Data laboratorium yang berhubungan
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b. Pemeriksaan Radiologi
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VII. DIAGNOSA MEDIS
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VIII. PENGOBATAN
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B. ANALISA DATA
DATA ETIOLOGI MASALAH
Diagnosa keperawatan berdasarkan prioritas :
1. ..
2. ..
3. ..
C. RENCANA KEPERAWATAN
NO DIAGNOSARENCANA KEPERAWATAN
TUJUAN INTERVENSI RASIONAL
D. IMPLEMENTASI
TANGGAL/JAM NO. DX IMPLEMENTASI RESPON KLIEN/ EVALUASI PARAFNAMA
E. EVALUASI/CATATAN PERKEMBANGAN
NO TANGGAL/ JAM NO DIAGNOSA EVALUASI PARAF
S :
O:
A:
P:
Mengetahui,
Pembimbing klinik/CI Mahasiswa
(...................................) (.............................................)
NIP. NIM.
Clinical Teacher/ CT
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NIP.