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Post Natal

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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