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ASUHAN KEBIDANAN PADA IBU NIFAS
NY... UMUR ....TAHUN G..P..A..AH.. DENGAN .................................
DI........................................
NO. RESGISTER :...................................................................................
MASUK TANGGAL, JAM :...................................................................................
TEMPAT :...................................................................................
TANGGAL, JAM PENGKAJIAN DATA :.........................................................
Biodata Ibu Suami
Nama :...............................................................................................
Umur :...............................................................................................
Agama :...............................................................................................
Suku/Bangsa :...............................................................................................
Pendidikan :...............................................................................................
Pekerjaan :...............................................................................................
Alamat :...............................................................................................
Nomor Telpon/ HP :...............................................................................................
DATA SUBJEKTIF
1. Alasan Datang
..............................................................................................................................
..............................................................................................................................
2. Keluhan Pasien
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Riwayat Menstruasi
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
4. Riwayat Perkawinan
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
5. Riwayat Kehamila, Persalinan dan Nifas Lalu
Hami
l ke -
Persalinan Nifas
LahirUmur
Kehamilan
Jenis
Persalinan
Penolon
g
Komplikasi J
K
BB
LahirLaktasi Komplikasi
Ibu Bayi
6. Riwayat Kontrasepsi Yang digunakan
No.Jenis
Kontrasepsi
Pasang Lepas
Tgl Oleh Tempat Keluhan Tgl Oleh Tempat Alasan
7. Riwayat Kehailan dan PersalinanTerakhir
Masa kehamilan :..................................................................................
Tempat Persalinan :..................................................................................
Komplikasi :..................................................................................
a. Partus lama :.....................................jam
b. KPD :.....................................jam
Placenta : lengkap/tidak
a. Lahir : spontan/manual.
b. Ukuran/berat :...................cm.................kg
c. Tali pusat : ..................cm, inersio :............................................
d. Kelainan :..................................................................................
Perinium : Utuh
Ruptur (derajat 1/2/3/totalis)
Episiotomi (medis/lateralis/mediolateralis)
Jahitan dalam ................... benang .........................
Jahitan luar........................ benang .........................
Jahitan jelujur.........................................................
Perdarahan Kala I
:..................................................................................
Kala II : .................................................................................
Kala III:..................................................................................
Kala IV:..................................................................................
Lama Persalinan Kala I : ..................................................................................
Kala II : .................................................................................
Kala III: .................................................................................
Kala IV: .................................................................................
Keadaan Bayi Baru Lahir
Lahir tanggal...........bulan........................tahun..............................
a. Masa Gastasi : .............................................................................................
b. BB/PB lahir : .............................................................................................
c. Nilai APGAR:1 menit/5 menit/10 menit/2 jam:...........................................
d. Cacat bawaan : .............................................................................................
e. Rawat gabung: .............................................................................................
8. Riwayat Kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
........................................................................................................................
........................................................................................................................
.......................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga
........................................................................................................................
........................................................................................................................
.......................................................................................................................
9. Riwayat Kontrasepsi
No.Jenis
Kontrasepsi
Pasang Lepas
Tgl Oleh Tempat Keluhan Tgl Oleh Tempat Alasan
10. Riwayat Postpartum
Pola nutrisi : Makan Minum
Frekuensi ...................................................................................
Macam ...................................................................................
Jumlah ...................................................................................
Keluhan ...................................................................................
Minum obat dan Vitamin :..................................................................................
...................................................................................
Alergi :...................................................................................
...................................................................................
Pola eliminasi BAB BAK
Frekuensi ...................................................................................
Warna ...................................................................................
Bau ...................................................................................
Konsistensi ...................................................................................
Keluhan ....................................................................................
Mobilisasi dan permasalahan :......................................................................
........................................................................
........................................................................
........................................................................
Keluhan jalan lahir :.......................................................................
.......................................................................
Lochea :.........................................................
.......................................................................
........................................................................
Kodisi pada jalan lahir :.......................................................................
.......................................................................
.......................................................................
.......................................................................
Pola tidur :...............................................................................................
...............................................................................................
...............................................................................................
Aktifitas :..............................................................................................
..............................................................................................
..............................................................................................
Personal hygine :...............................................................................................
...............................................................................................
..............................................................................................
Kelancaran ASI :...............................................................................................
...............................................................................................
...............................................................................................
Kebiasaan menyusu bayi :...................................................................................
...................................................................................
...................................................................................
Pola tidur bayi :...............................................................................................
...............................................................................................
...............................................................................................
11. Kondisi Psiko Sosial Spiritual
Psiko Ibu :...............................................................................................
...............................................................................................
...............................................................................................
Perawatan bayi :...............................................................................................
...............................................................................................
...............................................................................................
Peran suami :..............................................................................................
..............................................................................................
................................................................................................
Peran keluarga :..............................................................................................
..............................................................................................
..............................................................................................
Hubungan Ibu dengan Lingkungan : ..........................................................
...........................................................
...........................................................
Spiritual :...............................................................................................
...............................................................................................
...............................................................................................
DATA OBJEKTIF
1. Pemerikasaan Fisik
a. Keadaan umum :............................................... kesadaran: ........................
b. Tanda vital
Tekanan Darah : .......................mmHg
Nadi : ....................... kali permenit
Pernapasan : ....................... kali permenit
Suhu : ........................oC
c. TB : ........................ cm
BB : ........................ kg
LILA : ........................ cm
d. Kepala dan Leher
Rambut : .................................................................................
Edema wajah :..................................................................................
Mata : ...............................................................................
Mulut : ..................................................................................
Leher : ..................................................................................
e. Payudara
Bentuk :.................................................................................
Areoala mamae :.................................................................................
Puting susu :..................................................................................
Colostrum :..................................................................................
f. Abdomen
Bentuk :...................................................................................
Bekas luka :..................................................................................
TFU : ........................ cm
Kontraksi Uterus :..................................................................................
Kandung Kemih :..................................................................................
g. Ekstremitas
Edema :...................................................................................
Varises
:...................................................................................
Reflek patela : ...../.....
Kuku :...................................................................................
h. Genetalia luar
Edema : .................................................................................
Varises
: ..................................................................................
Perinium : ..................................................................................
Bekas jahitan :...................................................................................
Pengeluaran Lochea :
Jenis....................warna..................jumlah....................konsistensi
............................bau......................
i. Anus
Hemoroid :..................................................................................
2. Pemeriksaan penunjang
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
............................................................................................................................
ASSESMENT
1. Diagnosis Kebidanan
........................................................................................................................
......................................................................................................................
2. Masalah
........................................................................................................................
......................................................................................................................
3. Kebutuhan
........................................................................................................................
.......................................................................................................................
4. Diagnosis Potensial
........................................................................................................................
........................................................................................................................
5. Masalah Potensial
........................................................................................................................
.......................................................................................................................
6. Kebutuhan Tindakan Segera
a. Mandiri :
b. Kolaborasi :
c. Merujuk :
PLANNING
Tanggal :........................................................... Jam :..........................................