PROGRAM STUDI D III KEPERAWATAN

KEPERAWATAN MATERNITAS

ASUHAN KEPERAWATAN POSTPARTUM

Nama Mahasiswa : ___________________ Tanggal Pengkajian : ______________

NIM : ___________________ RS/Ruangan : ______________

A. PENGKAJIAN
1. PENGUMPULAN DATA
DATA UMUM KLIEN
Initial Klien : ..................................................................................................
Usia : ..................................................................................................
Pekerjaan : ..................................................................................................
Pendidikan Terakhir : ..................................................................................................
Agama : ..................................................................................................
Initial Suami : ..................................................................................................
Usia : ..................................................................................................
Pekerjaan : ..................................................................................................
Pendidikan Terakhir : ..................................................................................................
Agama : ..................................................................................................
Suku Bangsa : ..................................................................................................
Status Perkawinan : ..................................................................................................
Alamat : ..................................................................................................
RIWAYAT KEHAMILAN/ PERSALINAN YANG LALU
Keadaan
Jenis BB Bayi Masalah
No Tahun Jenis Persalinan Penolongan
kelamin Lahir Waktu Kehamilan
Lahir

Pengalaman Menyusui: ya/tidak Berapa lama: ..............................................

Riwayat Kehamilan Saat Ini
1. Perikasa hamil : .................................................. kali
2. Masalah kehamilan : ...................................................................................................

Riwayat Ginekologi
1. Masalah Ginekologi : ....................................................................................................

2. Riwayat KB : ....................................................................................................

Riwayat Persalinan
1. Jenis Persalinan : Spontan (Letkap/Letsu)/ Tindakan (EF/EV)
……SCa/l……tgl/jam…………………
2. Keadaan bayi
a. Jenis kelamin : L/P
b. BB/PB : ............................ gram/ .............................. cm, A/S:……….
3. Perdarahan : ............................ cc
4. Masalah dalam persalinan ...............................................................................................

DATA UMUM KESEHATAN SAAT INI

Status obstetrik : G.............P.............Ab..............

Rawat gabung : ya/tidak, jika tidak, alasan ...........................................................

Keadaan umum : ............................ Kesadaran: ................................................................
BB/TB : ............................ Kg/ .................................. cm
Tanda-tanda vital
TD...................., Suhu..............., Nadi..............., Pernafasan................

Kepala Leher
Kepala : ..............................................................................................................................
Mata : ..............................................................................................................................
Hidung : ..............................................................................................................................
Mulut : ..............................................................................................................................
...............................................................................................................................
Telinga : ..............................................................................................................................
Leher : ..............................................................................................................................
Masalah khusus .............................................................................................................................
Dada
Jantung : ..............................................................................................................................
Paru : ..............................................................................................................................
Payudara : ..............................................................................................................................
Puting susu :................................................................................................................

Warna areola :................................................................................................................

Kolostrum : .........................................................................................................................
Masalah khusus : .........................................................................................................................

Abdomen
Involusi uterus
Fundus uterus : ...........................................................................................................

Kandung kemih : ...........................................................................................................

Distraksi reptur abdomonalis: .........................x .............................. cm
Masalah khusus : ...........................................................................................................................

Perineum dan Genetalia

Vagina : ......................................................................................................................

Integritas kulit : ......................................................................................................................

Edema : ......................................................................................................................
Memar : ......................................................................................................................
Hematom : ......................................................................................................................
Perineum : utuh/episiotomi/ruptur

Tanda REEDA
R: Red : ya/tidak
E: Edema : ya/tidak
E: Echimosis : ya/tidak
D: Discharge : serum/pus/darah/tidak ada
A: Approximate : baik/tidak
 Kebersihan
 Lochea:
o Jumlah ...............................................................................................
o Jenis/warna ...............................................................................................
o Konsistensi ...............................................................................................
o Bau ...............................................................................................
o Hemorroid ...............................................................................................
 o Berapa lama ...............................................................................................
Masalah khusus ...........................................................................................................................
......................................................................................................................................................

Ekstremitas
Ekstremitas Atas
Edema: ya/tidak, lokasi .................................................................................................
Verises ya/tidak, lokasi ..................................................................................................
Ekstermitas Bawah
Edema: ya/tidak, lokasi .................................................................................................
Verises: ya/tidak, lokasi .................................................................................................
Refflek patella: +/-
Masalah khusus : .......................................................................................................................

Pola Eliminasi
Eliminasi Urin
Kebiasaan BAK : ..................................................................................................................
....................................................................................................................
BAK saat ini : ...................................................................................................................
Nyeri : ya/tidak
Eliminasi Alvi
Kebiasaan BAB : ...................................................................................................................
BAB saat ini : ...................................................................................................................
Konstipasi : ya/tidak
Masalah khusus ............................................................................................................................

Istirahat Dan Kenyamanan

Pola tidur
Kebiasaan tidur : Lama ....................... jam, frekuensi: .................................................
Pola tidur saat ini .........................................................................................................................
Keluhan ketidaknyamanan: ya/tidak,
Lokasi: ............................ Sifat: .............................. intensitas: .................................

Mobilisasi dan latihan

Tingkat mobilisasi : ..................................................................................................................
Latihan/senam : ...................................................................................................................
Masalah khusus : ...................................................................................................................
Nutrisi Dan Cairan
Asupan nutrisi : ......................................................
Nafsu makan : baik/kurang/tidak ada
Asupan cairan : cukup/kurang
Masalah khusus : .................................................................................................................

Keadaan mental
Keadaan psikologi : ...................................................................................................................

 Taking in : ...................................................................................................................
 Taking hold : ...................................................................................................................
 Letting go : ...................................................................................................................
Penerimaan terhadap bayi : ........................................................................................................
Masalah khusus : ........................................................................................................................
Kemampuan menyusui ..............................................................................................................
Obat-obatan
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Hasil pemeriksaan penunjang
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Perencanaan pulang
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