FORMAT PENGKAJIAN MATERNITAS - PENGKAJIAN POST PARTUM
FORMAT PENGKAJIAN MATERNITAS
PENGKAJIAN POST PARTUM
|
Nama
Mahasiswa
NIM
|
:
...............................................
:
...............................................
|
Tanggal
Pengkajian
Ruangan
/ RS
|
:
.................................................
:
.................................................
|
DATA
UMUM KLIEN
Inisial Klien : ........................................ Inisial Suami : ........................................
Usia :
........................................ Usia : ........................................
Status Perkawinan : ........................................ Status Perkawinan :
........................................
Pekerjaan :
........................................ Pekerjaan :
........................................
Pendidikan terakhir : ........................................ Pendidikan terakhir :
........................................
Alamat :
.............................................................................................................................................
Alamat :
.............................................................................................................................................
Riwayat
Kehamilan dan Persalinan yang lalu
|
No
|
Tahun
|
Jenis
Persalinan
|
Penolong
|
Jenis
Kelamin
|
BB
Lahir
|
Keadaan
Bayi Waktu Lahir
|
Masalah
Kehamilan
|
|
1
|
|
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
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3
|
|
|
|
|
|
|
|
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4
|
|
|
|
|
|
|
|
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5
|
|
|
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|
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Pengalaman menyusui: ya / tidak Berapa
lama: ...................................
Riwayat
Kehamilan Saat Ini:
1. Berapa
kali periksa kehmilan? ..................................................................................................................................
2. Masalah
kehamilan?
.................................................................................................................................................
Riwayat
Persalinan
1. Jenis
persalinan : Spontan ( letkep / letsu ) / SC / a/i .................... tgl/jam
........................................
2. Jenis
kelamin bayi : L / P , BB .................... gram, PB .......... cm, A/S:
..................................................................
3. Perdarahan
: .................... cc
4. Masalah
dalam persalinan:
........................................................................................................................................
Riwayat
Ginekologi
1. Masalah
ginekologi: ..................................................................................................................................................
2. Riwayat
KB:
.............................................................................................................................................................
Data
Umum Kesehatan Saat Ini
Status Obstetrik : P ............ A
............ bayi rawat gabung: ya / tidak
jika tidak, alasan: .................................................................................................................................
Keadaan umum :
.......................................................................................................
kesadaran: ..................................
BB ............... kg, TB ............... cm
Tanda Vital: TD :
......................... mmHg. Nadi : ............... Suhu :............... 
. Pernapasan :
.............. x/menit
. Pernapasan :
.............. x/menit
Kepala
Leher
·
Kepala :
............................................................................................................................................................
·
Mata :
............................................................................................................................................................
·
Hidung :
............................................................................................................................................................
·
Mulut :
............................................................................................................................................................
·
Telinga :
............................................................................................................................................................
·
Leher :
............................................................................................................................................................
Masalah Khusus : ............................................................................................................................................................
Dada
·
Jantung :
.............................................................................................................................................
·
Paru :
.............................................................................................................................................
·
Payudara :
.............................................................................................................................................
·
Puting susu : .............................................................................................................................................
·
Pengeluaran ASI :
.............................................................................................................................................
Masalah Khusus :
.............................................................................................................................................
Abdomen
·
Involusi uterus: .........................................................................................................................................................
·
Fundus uterus:
........................................ kontraksi:
........................................ posisi: ............................................
·
Kandung kemih:
........................................................................................................................................................
·
Fungsi pencernaan:
...................................................................................................................................................
Masalah Khusus: ..............................................................................................................................................................
Perineum
dan Genital
Vagina: Integritas kulit:
......................... Edema: ......................... Memar:
......................... Hematoma: .......................
Perineum: utuh / episiotomi / ruptur
Tanda
REEDA
R : Kemerahan: Ya / Tidak
E : Bengkak: Ya / Tidak
E : Echimosis: Ya / Tidak
D : Discharge: Serum / Pus / Darah / Tidak ada
A : Approximate: Baik / Tidak
Kebersihan:
...............................................................................................................................................................
Lokea :
jumlah .............................. jenis ..............................
warna ..............................
: konsistensi ............................... bau
.....................................’
Hemorhoid: derajat
.............................. lokasi .............................. berapa
lama .............................. nyeri: ya / tidak
Masalah khusus: ...............................................................................................................................................................
Ekstremitas
Ekstremitas Atas : Edema ( ya / tidak ), lokasi ..........................................................................................................
Ekstremitas bawah : Edema ( ya / tidak ), lokasi
..........................................................................................................
Varises : ya / tidak , lokasi
..........................................................................................................................
Tanda Hoffman : + / -
Masalah khusus :
......................................................................................................................................................
Eliminasi
Urin :
Kebiasaan BAK .................................................. BAK saat ini
.............................. nyeri: ya / tidak
BAB :
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
..........................
Mobilitas
dan Latihan
·
Tingkat mobilisasi
.....................................................................................................................................................
·
Latihan/senam
...........................................................................................................................................................
Masalah khusus: ...............................................................................................................................................................
Nutrisi
dan Cairan
Asupan nutrisi :
............................................................................
nafsu makan: bak / kurang / tidak ada
Asupan :
............................................................................
cukup / kurang
Masalah khusus :
............................................................................................................................................................
Keadaan
Mental
·
Adaptasi psikologis :
.............................................................................................................................................
·
Penerimaan terhadap bayi: ........................................................................................................................................
·
Masalah khusus :
.............................................................................................................................................
·
Obat-obatan :
.............................................................................................................................................
Obat-obatan :
.............................................................................................................................................
Keadaan umum :
.......................................................................................................
kesadaran: ..................................
Tanda Vital: TD :
......................... mmHg. Nadi : ............... Suhu :............... . Pernapasan :
.............. x/menit
. Pernapasan :
.............. x/menit
Jenis persalinan .........................................................
Proses persalinan
.........................................................................
Kala I ..................................
jam
Indikasi
.............................................................................
Kala II ............................................................... menit
Komplikasi persalinan: ibu
........................................................ janin
............................................................................
Lamanya ketuban pecah
..................................................................... kondisi
ketuban ..................................................
Keadaan
Bayi Saat Lahir
Lahir tanggal:
..................................................... jam
.......................................... jenis kelamin
.....................................
Kelahiran: tunggal / gemelli
Nilai APGAR
|
Tanda
|
Nilai
|
∑
|
||
|
0
|
1
|
2
|
||
|
·
Denyut jantung
|
(
) tidak ada
|
(
) < 100
|
(
) > 100
|
|
|
·
Usaha napas
|
(
) tidak ada
|
(
) lambat
|
(
) menangis kuat
|
|
|
·
Tonus otot
|
(
) lumpuh
|
( ) ekstremitas fleksi sedikit
|
(
) gerakan aktif
|
|
|
·
Iritabilitas reflek
|
(
) tidak bereaksi
|
(
) gerakan sedikit
|
( ) reaksi melawan
|
|
|
·
Warna
|
(
) biru/pucat
|
( ) tubuh kemerahan, tangan dan kaki biru
|
(
) kemerahan
|
|
|
TOTAL
|
|
|||
Keterangan:
Tindakan resusitasi : .............................................................................................................................................
Plasenta :
berat
....................................................................................................................................
Ukuran :
.............................................................................................................................................
Tali pusat :
............................................................. panjang
..................................................................
Jumlah pembuluh darah :
.............................................................................................................................................
Kelainan :
.............................................................................................................................................
Pemeriksaan penunjang :
.............................................................................................................................................
...........................................................................................................................................................................................
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Masalah:
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Perencanaan pulang:
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