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