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
3
4
5

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

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

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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