FORMAT PENGKAJIAN ASUHAN KEPERAWATAN POST NATAL KEPERAWATAN MATERNITAS

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN POST NATAL

KEPERAWATAN MATERNITAS

Nama Mahasiswa :

NIM :

Tempat Praktek :

Tanggal :

Pengkajian :

Praktik :

I. IDENTITAS PASIEN

Nama : ......................................................................................

Umur : ......................................................................................

Status Perkawinan : ......................................................................................

Agama : ......................................................................................

Suku : ......................................................................................

Pendidikan : ......................................................................................

Nama Suami : ......................................................................................

Umur Suami : ......................................................................................

Alamat : ......................................................................................

Pekerjaan : ......................................................................................

Diagnosa Medis : ......................................................................................

Tanggal Masuk RS : ......................................................................................

II. KELUHAN UTAMA

....................................................................................................................................

III. RIWAYAT PERSALINAN DAN KELAHIRAN SAAT INI

· Lama persalinan : ......................................................................................

· Posisi fetus : ......................................................................................

· Tipe kelahiran : ......................................................................................

· Penggunaan analgetik dan anastesi : ...............................................................

· Masalah selama persalinan : .............................................................................

IV. DATA BAYI SAAT INI

....................................................................................................................................

V. KEADAAN PSIKOLOGI IBU

....................................................................................................................................

VI. RIWAYAT PENYAKIT DAHULU

....................................................................................................................................

VII. RIWAYAT PENYAKIT KELUARGA

....................................................................................................................................

Genogram

Keterangan :

: laki-laki : perempuan

/ : meninggal

: tinggal serumah

: klien

VIII. RIWAYAT GINEKOLOGI

....................................................................................................................................

IX. RIWAYAT GINEKOLOGI

· Menarche usia : ...... tahun

· Siklus menstruasi : teratur / tidak, .............hari

· Karakteristik mens : ......................................................................................

· G.....P....A.....

· HMT : ......................................................................................

· HPL : ......................................................................................

· Keluhan selama kehamilan ini :

Trimester I : ..................................................................................................

Trimester II : ..................................................................................................

Trimester III : ..................................................................................................

X. RIWAYAT PENYAKIT DAHULU

....................................................................................................................................

XI. RIWAYAT PENYAKIT KELUARGA

....................................................................................................................................

XII. PEMERIKSAAN FISIK

Keadaan umum : .......................................BB : .......kg, TB : ..........cm

TTV : P :........x/menit, BP :..........mmHg, R :.......x/menit, T :.........°C

Kepala : ..............................................................................................................

Leher : ..............................................................................................................

THT : ..............................................................................................................

Thoraks : ..............................................................................................................

Abdomen : ............................................................................................................

Genital : ..............................................................................................................

Anus dan rectum : ................................................................................................

Muskuloskletal : ..................................................................................................

XIII. PROFIL KELUARGA

.............................................................................................................................................................................................................................................................................................................................................................................................

XIV. KELUARGA BERENCANA

XV. PEMERIKSAAN PENUNJANG

Hari/tanggal/jam	Jenis pemeriksaan	Hasil	Interpretasi

XVI. TERAPI YANG DIPEROLEH

Hari/tanggal/jam	Jenis Terapi	Rute Pemberian	Dosis	Indikasi Terapi

XVII. ANALISA DATA

DATA	PROBLEM	ETIOLOGY