Pnc Nifas.docx

A. FORMAT PENGKAJIAN PROGRAM PENDIDIKAN PROFESI NERS FAKULTAS ILMU-ILMU KESEHATAN UNIVERSITAS NUSA NIPA MAUMERE 2016

Tanggal MRS

KEPERAWATAN POSTNATAL CARE ( NIFAS )

:

No. Reg ( CM )

Jam pengkajian :

:

Diagnosa medis :

Pengkajian tanggal :

I. IDENTITAS  IBU ( ISTRI )

 SUAMI ( PENANGGUNG JAWAB )

Nama

:...................................................................

Nama

:...................................................................

Umur

: .................................................................

Umur

: .................................................................

Pekerjaan

: .................................................................

Pekerjaan

: .................................................................

Suku/bangsa

: .................................................................

Suku/bangsa

: .................................................................

Agama

: .................................................................

Agama

: .................................................................

Alamat

: .................................................................

Alamat

: .................................................................

Status perkawinan : .................................................................

Status perkawinan : .................................................................

II. STATUS PERKAWINAN  Menikah berapa kali

: ...................................................................................

 Umur menikah pertama

: ...................................................................................

 Usia Pernikahan Terakhir

: ...................................................................................

III. RIWAYAT KESEHATAN  Keluhan utama

: .........................................................................................

 Riwayat penyakit sekarang

:..........................................................................................

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

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 Penyakit yang di derita

: .........................................................................................

........................................................................................................................................................ ........................................................................................................................................................  Penyakit yang pernah dialami

: .........................................................................................

........................................................................................................................................................ .......................................................................................................................................................  Penyakit keturunan

: ........................................................................................

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

IV. RIWAYAT KEHAMILAN :

G……..

P……..

A……

 Masa gestasi

: ……………….. minggu

 Kelainan selama hamil

: ........................................................................................

 Tanggal persalinan terakhir

: ........................................................................................

 Jenis persalinan

: Spontan / Tindakan

 Lama persalinan

: ........................................................................................

 Perdarahan

: ........................................................................................

 Penyulit persalinan

: Ada / Tidak

 Keadaan anak

: Hidup / Mati, BB….. gr, PB……. gr, LK………cm

 Apgar score

: ........................................................................................

 Kelainan bawaaan

: ........................................................................................

 Rawat gabung

: Ya / Tidak

V. ADL NO

STATUS

SELAMA KEHAMILAN

NUTRISI : Menu makanan 1

Porsi pantangan Keluhan CAIRAN: Jenis minuman

2

Porsi Pantangan Keluhan BAB :

3 Frekuensi

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SETELAH MELAHIRKAN

Konsistensi Warna/bau keluhan BAK : Frekuensi Konsistensi Warna/bau keluhan AKTIVITAS Kegiatan sehari – hari 4 Keterbatasan Kemampuan otot ISTIRAHAT TIDUR : Pola tidur 5

Waktu Gangguan tidur Keluhan Personal hygiene Mandi Keramas

6 Gosok gigi Ganti pakaian Keluhan

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VI. DATA PSIKOSOSIAL / KOGNITIF / PRESEPTUAL a. Bonding :

sangat negative ( score 3 – 6 ) Sangat positif ( sore 10 – 12 )

Grafik penilaian interaksi orangtua dan bayi ( bonding Attacment ) Score bonding score 1

Bagaimana tindakan ibu terhadap bayinya

bonding

memandang

Sangat negative Penampilan dan sangat tidak depresi, tepat

berkata

umum Membuat

Melakukan sesuatu sesuatu Memfokuskan

ketakutan, sebutan bagi bayi & perhatian pada dirinya

marah, apatis

suaminya

Menolak melihat kea

Memperlihatkan

rah

permusuhan

/

bayinya

:

rasa menangis

kecewa terhadap jenis kelamin bayinya 2

Agak negative dan tidak tepat

3

Agak positif,sesuai

4

Sangat positif

Sangat

gembira, Berbicara

dan sesuai

bahagia dan antusias

langsung Mengulurkan

tangan

pada

bayi ingin

memegang,

menggunakan

nam memeriksa, membuat

bayinya

dan kontak mata dengan

memperlihatkan reaksi bayinya positif

b. Taking in : Berorientasi pada diri sendiri

:

ya

tidak

Takut ketergantungan meningkat :

ya

tidak

c. Taking hold : Mulai tertarik pada bayi

:

ya

tidak

Perawatan mandiri

:

ya

tidak

d. Post partum blues : After pain

:

ya

tidak

e. Pengetahuan Ibu tentang : Perawatan bayi

: ........................................................................................

................................................................................................................................................ Menyusui

: ........................................................................................

................................................................................................................................................ Makanan bayi

: ........................................................................................

................................................................................................................................................ Senam nifas

: ........................................................................................

................................................................................................................................................ Perawatan payudara

: ........................................................................................

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Tanda – tanda komplikasi

: ........................................................................................

................................................................................................................................................ Hub. Sex post partum

: ........................................................................................

................................................................................................................................................ f.

Tanggapan Ibu tentang menggunakan KB: Ada rencana

tidak ada rencana

Kapan

: .............................................................................................................

Metode

: .............................................................................................................

Tanggapan suami

: .............................................................................................................

g. Tanggapan keluarga atas kelahiran bayi : ..................................................................... ................................................................................................................................................ ................................................................................................................................................ h. Kebiasaan / adat / yang berkaitan dengan masa nifas / BBL : ........................................ ................................................................................................................................................ ................................................................................................................................................

VII. PEMERIKSAAN FISIK IBU 1. Tanda – tanda Vital : Tekanan darah / tensi

: ……......................

mmHg

Suhu

: ……......................

Celcius

Nadi

: ……......................

x/menit

RR

: ……......................

x/menit

2. Keadaan umum a. Tampak sakit

: Berat / Sedang / Ringan / Tidak Sakit

b. Kesadaran

: ........................................................................................................................

c. Konjungtiva

: ........................................................................................................................

d. Sclera

: ........................................................................................................................

3. Keadaan Payudara

:

a. Bentuk

: Simetris / Tidak

b. Putting

:

Menonjol

Tertarik Kedalam

Lecet

Tidak Lecet

Berbelah

Tidak Berbelah

c. Pengeluaran ASI

: Ada / Tidak Ada, Lancar / Tidak Lancar

d. Bendungan ASI

: Ada / Tidak Ada

4. Abdomen a. TFU Kontraksi uterus b. Posisi uterus

Datar

: : ..................................................................................................... : ..................................................................................................... : .....................................................................................................

c. Distensi rectus abdominalis : .....................................................................................................

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5. Vulva / perineum / rectum : a. Lochea

: ........................................................................................................................

Warna

: ........................................................................................................................

Jenis

: ........................................................................................................................

Banyaknya

: ........................................................................................................................

Bau

: ........................................................................................................................

b. Kebersihan

: ........................................................................................................................

c. Oedema

: Ada / Tidak

d. Varices

: Ada / Tidak

e. Haemoroid

: Ada / Tidak

f. Luka Jahitan

: Ada / Tidak

g. Keadaan luka : R :...............................................................................................................................................

E : ...............................................................................................................................................

E : ...............................................................................................................................................

D : ...............................................................................................................................................

A : ...............................................................................................................................................

6. Tungkai bawah

: .........................................................................................................................

Tromboplebitis

: .........................................................................................................................

Tanda human

: .........................................................................................................................

Oedema

: .........................................................................................................................

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VIII. PEMERIKSAAN PENUNJANG Tanggal

Pemeriksaan

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No

Kriteria

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Hasil Pemeriksaan

Nilai Normal

Satuan

IX. TERAPY TgL

No

Dosis

Cara

(Kandungan Obat)

Pemberian

Terapi

Indikasi

Kontra Indikasi

……….……………, ………………………2016 Mengetahui Pengkaji

(

Praktek Program Profesi Ners 2016

CI Ruangan

)

(

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)

B. KLASIFIKASI DATA : Hari / Tanggal

: ……………………………...........................................................................

Nama Klien/ Usia

: …………………………....... / .....................................................................

Diagnosa Medis

: ……………………………...........................................................................

DATA SUBYEKTIF : .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................

DATA OBYEKTIF : (Termasuk Hasil Pemeriksaan Fisik, Monitoring, dan Pemeriksaan Penunjang) .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... .........................................................................................................................................................................

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C. ANALISA DATA

Hari / Tanggal

: ……………………………...........................................................................

Nama Klien/ Usia

: …………………………....... / .....................................................................

Diagnosa Medis

: ……………………………...........................................................................

No

Data

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Etiologi

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Problem (NANDA)

D. DIAGNOSA KEPERAWATAN

Hari / Tanggal

: ……………………………...........................................................................

Nama Klien/ Usia

: …………………………....... / .....................................................................

Diagnosa Medis

: ……………………………...........................................................................

PRIORITAS MASALAH KEPERAWATAN :

1. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 2. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 3. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 4. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 5. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 6. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 7. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................ 8. ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................

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E. PATOFLOW KASUS

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Contoh Format SALIN di lembar bagian tengah Double Folio Bergaris

F. RENCANA KEPERAWATAN DEPARTEMEN ........................................................... NAMA KLIEN

: ............................................................................................................................. .......

NAMA MAHASISWA

: ......................................................

NIRM

: ....................................................................................................................................

PROGRAM

: ...........................................................

DIAGNOSA MEDIS

: ....................................................................................................................................

INSITITUSI

: .......................................................

BANGSAL / TEMPAT

: ................................................................................................................ ....................

No

TGL

KONFIRMASI DATA

DIAGNOSA KEPERAWATAN (NANDA)

REKAM MEDIK

PASIEN

AKTUAL /

TUJUAN DAN

RENCANA

RESIKO / PK /

KRITERIA HASIL

KEPERAWATAN (NIC)

WELLNESS

(NOC)

DAN RASIONAL

IMPLEMENTASI

PARAF EVALUASI

Tgl / Jam

PELAKSANAAN

Mahasiswa

1 .... Pemeriksaan

DS :

Penunjang: 

R/ ....

S:

2. ...

O:

R/ ....

Lab, Rontgen, Ct

DO :

Scan, MRI,

 Obser-

dsb.

vasi

Dst..

P:

(Berdasarkan ONEC, yaitu 

 PemFis Monitoring

A:

Observation (Observasi)



Nursing (Tindakan Mandiri Perawat)



Education (Pendidikan Kesehatan)



Collaboration (Kolaborasi Medis, Paramedis, dan Keluarga)

Asuhan Keperawatan Maternitas_Post Natal Care (PNC)

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CI / CT

Asuhan Keperawatan Maternitas_Post Natal Care (PNC)

14

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