PENGKAJIAN POST NATAL
Nama Mahasiswa: .............................................................................................Tanggal Pengkajian:..............................................................................................Jam :..............................................................................................Ruangan/RS:..............................................................................................
I. Identitas Penanggung-jawab klienNama:..............................................................................................Umur :..............................................................................................Pekerjaan :..............................................................................................Hub. Keluarga:..............................................................................................
II. Identitas KlienNama :..............................................................................................No. RM :..............................................................................................Tgl. Masuk RS:..............................................................................................Umur:..............................................................................................Pekerjaan:..............................................................................................Status Obstetrik:..............................................................................................
Anak keTipe persalinanBb. LahirKeadaan Bayi Baru LahirKomplikasi NifasUmur
III. Keluhan UtamaIV. Riwayat Kesehatan Sekarang
V. Riwayat Kehamilan
VI. Riwayat Menstruasi Menarche Umur :..............................................................................................Siklus menstruasi:..............................................................................................Lama menstruasi:..............................................................................................Adakah gangguan dalam menstruasi, Jika ada bagaimana cara mengatasinya?
VII. Riwayat KBJenis KB: ..............................................................................................Lama KB :..............................................................................................Adakah keluhan :..............................................................................................Jika ada bagaimana cara mengatasinya?
VIII. Pemeriksaan Fisik (Head To Toe)1. Tanda vital: ..................................................................................2. Keadaan umum:..................................................................................3. Kulit, kuku :..................................................................................4. Kepala, leher:..................................................................................5. Thorak, patudara:..................................................................................6. Abdomen:..................................................................................7. Linea nigra:..................................................................................Tinggi fundus uteri: .....................................................................Kekuatan kontraksi :......................................................................Diastasis rectus abdominis:......................................................................8. Perianal :..................................................................................a. Kebersihan :..................................................................................b. Keutuhan :..................................................................................c. Tanda REEDA:..................................................................................d. Lochea 1) Jumlah :.................................................................................. ..................................................................................2) Warna:.................................................................................. ..................................................................................3) Jenis lochea :.................................................................................. ..................................................................................4) Hemorhoid :.................................................................................. ..................................................................................e. Ekstrimitas 1) Varises : .................................................................................. ..................................................................................2) Tanda homan: .................................................................................. ..................................................................................
IX. Pengkajian Kebutuhan Khusus1. Oksigenisasi ..............................................................................................................................................................................................................................................................................................................................................................................2. NutrisiAsupan makanan Ibu : ..................................................................................Jenis : ............................... Jumlah: ....................................Nafsu makan :Bila tidak nafsu makan, alasannya?3. Cairan Asupan cairan:..................................................................................Jenis:..................................................................................Jumlah :..................................................................................Adakah pembatasan asupan cairan? Bila ada alasannya?..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Eliminasi Adakah keluhan keringat berlebihan? Bila ada, upaya mengatasinya?BAK pertama setelah persalinan Jam: ......................................Adakah keluhan BAK? Bila ada jelaskan!
BAB setelah persalinan Jam:........................................Adakah keluhan BAB? Bila ada jelaskan!
5. Kenyamanan 6. Istirahat dan Tidur
Riwayat Penyakit Terdahulu
Penyakit dahulu : ..Imunisasi: ..Riwayat rawat di RS: ..Alergi obat/makanan: ..Obat-obatan yang telah dikonsumsi :
Riwayat Penyakit Keluarga Hipertensi Penyakit pembuluh darah Diabetes Militus Penyakit Darah Lain-lain
Genogram:
Pemeriksaan Penunjang
WaktuJenis Pemeriksaan Hasil Pemeriksaan Nilai Rujukan
Tgl danJam
Terapi Obat
WaktuJenis Obat Dosis
Tgl danJam
Analisa Data
WaktuSymptom/signsEtiologi Problem
Tgl danJam
Diagnosa keperawatan dan prioritas masalah
1. 2. 3. 4. 5.
Intervensi
WaktuNo. DxTujuan Keperawatan(NOC)Rencana Tindakan(NIC)Ttd
Hari/Tgl.Jam
WaktuNo. DxTujuan Keperawatan(NOC)Rencana Tindakan(NIC)Ttd
Hari/Tgl.Jam
Catatan Perkembangan
Diagnosa Keperawatan : Shift Jaga:
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
Catatan Perkembangan
Diagnosa Keperawatan : Shift Jaga:
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
Catatan Perkembangan
Diagnosa Keperawatan : Shift Jaga:
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
WaktuImplementasiEvaluasiTtd
TglJam
Evaluasi
WaktuDx. Keperawatan EvaluasiTtd
TglJam
Evaluasi
WaktuDx. Keperawatan EvaluasiTtd
TglJam
