ASUHAN KEPERAWATAN POST PARTUM

A. Data Umum KlienInisial klien: ................(.....thn) Nama Suami: ....................(......thn)Pekerjaan : .......................... Pekerjaan: ..................................Pendidikan: .......................... Pendidikan : ..............................Agama: .......................... Agama: ..................................Suku bangsa: ..........................Status perkawinan : .........................Alamat: .............................................................................................

B. Riwayat Kehamilan dan Persalinan Yang LaluNoTahunJenis PersalinanPenolongJK bayiKeadaan Bayi Waktu LahirMasalah Kehamilan

1

2

3

4

Pengalaman Menyusui : ya / tidakBerapa lama :

C. Riwayat Kehamilan saat ini1. Berapa kali periksa kehamilan :.... Dimana...................................2. Masalah kehamilan: .............3. Data Tambahan: ...........................................................................................................................................................................................................................................

D. Riwayat Persalinan1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV,EF)SC ......................... Tgl/jam :...............2. Jenis kelamin bayi : L/P, BB/PB :..............gram/..........cm3. Perdarahan :...........................cc4. Masalah dalam persalinan .................................................................E. Riwayat Ginekologi1. Masalah ginekologi: ........................................................................................................................................2. Riwayat KB: ................F. Data Umum Kesehatan Saat Ini1. Status obstetrik : G..... A..... Post Partum hari ke...........2. Keadaan umum :.................Kesadaran :................BB/TB :.............Kg..................cm3. Tanda VitalTekanan Darah:.............mmHgNadi:.................... x/mntSuhu:............... CPernapasan : ...............x/mnt4. Kepala LeherKepala: .............................................................................................Mata: .............................................................................................Hidung: ............................................................................................Mulut: .............................................................................................Telinga: ..............................................................................................Leher: ..............................................................................................Masalah Keperawatan : ...............................................................................5. DadaJantung : .............................................................................................Paru: .............................................................................................Payudara: .............................................................................................Puting susu: .............................................................................................Pengeluaran ASI: .......................................................................................Masalah Keperawatan : ..............................................................................6. AbdomenInvolusi UterusFundus Uteri :....................kontraksi : .................Posisi :......................Fungsi pencernaan : ....................................................................................Data Tambahan: ...........................................................................................................................................................................................................................................Masalah Keperawatan : .............................................................................7. Perineum dan GenitalVagina : integritas kulit..........Edema..........Memar.........Hematom.........Perineum : Utuh/episiotomi/ruptur Tanda REEDAR : Kemerahan : ya/tidakE : Edema : ya/tidakE : Ekimosis : ya/tidakD :Dischargeserum/pus/darah/tidakadaA : Approximate : baik/tidakKebersihan :.............................................................................Lokia Jumlah : .................................. Jenis/warna :...............................Konsistensi : ............................ Bau : .........................................HemorrhoidDerajat :................................... Lokasi : .........................................Berapa lama : ......................... Nyeri : ya/tidakMasalah Keperawatan :...............................................................................8. EkstremitasEkstremitas Atas: Edema : ya/tidakVarises : ya/tidakEkstremitas Bawah: Edema : ya/tidakVarises : ya/tidakTanda Homan : +/-Refleks patela : +/- jika ada : +1/+2/+3Masalah Keperawatan : ...........9. EliminasiUrin : kebiasaan BAK.............BAK saat ini......................................Nyeri/tidakFekal : kebiasaan BAB................................................................................BAB saat ini.....................................Konstipasi: ada/tidakMasalah Keperawatan :................................................................................10. Istirahat dan KenyamananPola tidur : kebiasaan tidur : lama.............jam, Frekuensi...........................Pola tidur saat ini.........................................................................................Keluhan ketidaknyamanan : ya/tidak, lokasi...............................................Sifat................................intensitas........................................................11. Mobilisasi dan LatihanTingkat mobilisasi :...........................................................................Latihan/senam : ................................................................................Masalah Keperawatan : .....................................................................12. Nutrisi dan CairanAsupan Nutrisi : Nafsu Makan : Baik/Kurang/Tidak AdaAsupan Cairan : Cukup/KurangData Tambahan: ...........................................................................................................................................................................................................................................Masalah Keperawatan : ...............................................................................13. Keadaan MentalAdaptasi psikologis : ..................................................................................Penerimaan terhadap bayi :.........................................................................Masalah Keperawatan : ..............................................................................14. Kemampuan Menyusui: ..........................................................................................................................................................................................................................................................................................................................Masalah Keperawatan : ...............................................................................

15. Obat-obatan yang dikonsumsi saat ini.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

16. Hasil pemeriksaan penunjang Laboratorium tgl .................PemeriksaanHasilNilai NormalPemeriksaanHasilNilai Normal

G. Analisa DataNo.Data FokusEtiologiMasalah Keperawatan

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H. Diagnosa KeperawatanNo.Diagnosa Keperawatan

I. Rencana Asuhan KeperawatanNoDiagnosa keperawatanRencana Tindakan Keperawatan

Tujuan dan Kreteria hasilIntervensi

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J. Catatan PerkembanganNoHari/TglJam DXImplementasiEvaluasiParaf

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