TUGAS KONSEP KEBIDANAN

OLEH :

Kelompok 3

1. Lianti Lestari

2. Liska Milawati

3. Melan Melinda

4. Merry Andriana

5. Ni Putu Eka Yudiartini

6. Novensky Edorina Manuhutu

7. Nur Fitrianingsih

AKADEMI KEBIDANAN PARAMATA RAHA

KABUPATEN MUNA

2012

FORMAT PENGKAJIAN pada IBU NIFAS (PNC)

Tanggal masuk : ................................. Jam : ....................................

Tanggal partus : ................................. Jam : ....................................

Tanggal pengkajian : ................................... Jam : ....................................

LANGKAH I IDENTIFIKASI DATA DASAR

A. IDENTIFIKASI ISTRI/SUAMI

Nama : ............................/..............................

Umur : ............................/..............................

Suku : ............................/..............................

Agama : ............................/...............................

Pendidikan : ............................/...............................

Pekerjaan : ............................/...............................

Pernikahan : ............................./..............................

Lama menikah : ............................../..............................

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

B. DATA BIOLOGIS / FISIOLOGIS

1. Keluhan Utama : ................................................

2. Riwayat Keluhan Utama

a. Mulai timbulnya : ...............................................

b. Sifat keluhan : ...............................................

c. Lokasi keluhan : ...............................................

d. Faktor predisposisi : ...............................................

e. Pengaruh keluahan terhadap fungsi tubuh : ...............................................

f. Usaha klien mengatasi keluhan : ..............................................

3. Riwayat Kesehatan yang Lalu

a. Imunisasi yang diperoleh : ....................................................

b. Penyakit yang diderita : ....................................................

c. Riwayat opname : ......................................................

d. Riwayat operasi : .....................................................

e. Riwayat trauma : ....................................................

f. Riwayat transfuse darah : ....................................................

g. Riwayat alergi obat atau makanan : ...............................................

h. Ketergantungan terhadap sesuatu : ............................................

4. Riwayat Kesehatan Keluarga

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

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5. Riwayat Reproduksi

a. Riwayat haid

a. Menarche : .....................

b. Siklus haid : .....................

c. Durasi haid : .....................

d. Perlangsungan : .....................

e. Dismenorhoe : ....................

b. Riwayat obstetric

a. Riwayat kehamilan, persalinan dan nifas yang lalu

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b. Riwayat kehamilan sekarang

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c. Riwayat persalinan sekarang

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6. Riwayat Ginekologi

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7. Riwayat KB

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8. Riwayat Pemenuhan Kebutuhan Dasar

a. Pola Nutrisi

1. Kebiasaan

a. Pola makan : .........................................

b. Jenis makanan : .........................................

c. Frekuensi makan : .........................................

d. Nafsu makan : .........................................

e. Kebutuhan cairan : .........................................

2. Perubahan setelah melahirkan :

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

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

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

b. Kebutuhan Eliminasi

1. Buang air Kecil (BAK)

a. Kebiasaan sehari-hari

1. Frekuensi : ................................

2. Warna/bau : ................................

3. Gangguan buang air kecil : ................................

b. Perubahan setelah melahirkan : ................................

2. Buang Air Besar (BAB)

a. Kebiasaan sehari-hari

1. Frekuensi : ........................................

2. Warna / konsistensi : ........................................

3. Gangguan buang air besar : ........................................

b. Perubahan setelah melahirkan : .........................................

c. Pola Istrahat / tidur

1. Kebiasaan Istrahat / tidur sehari-hari

a. Tidur siang / istrahat siang : ..........jam

b. Tidur malam / istrahat malam : ..........jam

2. Perubahan setelah melahirkan : ................................

d. Personal Hygiene

1. Kebiasaan sehari-hari

a. Rambut : ...........................................

b. Gigi dan mulut : ...........................................

c. Badan : ............................................

d. Genitalia : ............................................

e. Pakaian : ...........................................

f. Kuku tangan dan kaki : ..........................................

2. Perubahan setelah melahirkan : ............................................

C. PEMERIKSAAN FISIK

1. Pemeriksaan Umum

a. Keadaan umum ibu : ...................................

b. Kesadaran : ....................................

c. Ekspresi wajah : ....................................

d. Berat badan : .....................................kg

e. Tinggi badan : .....................................cm

2. Pemeriksaan tanda-tanda vital

a. Tekanan darah : ....................mmhg

b. Nadi : ...................x/menit

c. Suhu : ....................0C

d. Pernapasan : ....................x/menit

3. Pemeriksaan obstetri (Inspeksi, Palpasi dan Perkusi)

a. Kepala / Rambut

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

b. Wajah

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

c. Mata

Inspeksi : ............................................................................................

d. Hidung

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

e. Telinga

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

f. Mulut dan Gigi

Inspeksi : ...........................................................................................

g. Leher

Palpasi : ............................................................................................

h. Payudara

Inspeksi : ...........................................................................................

Palpasi : ...........................................................................................

i. Abdomen

Inspeksi : ...........................................................................................

Palpasi : ...........................................................................................

j. Genitalia dan anus

Inspeksi : ..........................................................................................

k. Ekstremitas atas/bawah

Inspeksi : ........................................................................................

Palpasi : .........................................................................................

Perkusi : ..........................................................................................

D. DATA PSIKOLOGIS

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E. DATA SOSIAL

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F. DATA SPIRITUAL

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LANGKAH II. IDENTIFIKASI DIAGNOSA/MASALAH AKTUAL

a. Data Subyektif : ibu mengatakan ......................................................

b. Data Obyektif : ......................................................................................

LANGKAH III. IDENTIFIKASI DIAGNOSA/ MASALAH POTENSIAL

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LANGKAH IV. PERLUNYA TINDAKAN SEGERA / KOLABORASI

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LANGKAH V. RENCANA ASUHAN

A. Tujuan : 1. ................................................................................................

2. ...............................................................................................

3. ...............................................................................................

4. ...............................................................................................

5. ...............................................................................................

B. Kriteria

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C. RENCANA TINDAKAN

1. ....................................................................................................................

2. ....................................................................................................................

3. ....................................................................................................................

4. ....................................................................................................................

5. ....................................................................................................................

LANGKAH VI. IMPLEMENTASI

Tanggal : ..................................................... Jam : ........................................

1. ....................................................................................................................

Hasil :

2. ....................................................................................................................

Hasil :

3. ....................................................................................................................

Hasil :

4. ....................................................................................................................

Hasil :

5. ....................................................................................................................

Hasil :

LANGKAH VII EVALUASI

Tanggal : ......................................................... Jam : .................................................

1. ....................................................................................................................

2. ....................................................................................................................

3. ....................................................................................................................

4. ....................................................................................................................

5. ....................................................................................................................

FORMAT PENDOKUMENTASIAN pada IBU NIFAS

( PNC)

IDENTIFIKASI ISTRI / SUAMI

Nama : ........................................../......................................................

Umur : ........................................../.....................................................

Suku : .........................................../....................................................

Agama : .........................................../....................................................

Pendidikan : ............................................/...................................................

Pekerjaan : .........................................../....................................................

Pernikahan : ............................................/..................................................

Lama menikah : ............................................./...................................................

Alamat : ............................................../.................................................

DATA SUBYEKTIF (S)

1. Ibu mengatakan...............................................................................................

2. Ibu mengatakan...............................................................................................

3. Ibu mengatakan...............................................................................................

4. Ibu mengatakan...............................................................................................

5. Ibu mengatakan...............................................................................................

DATA OBYEKTIF (O)

1. Masa nifas hari ke-.....

2. Pemeriksaan umum

a. Keadaan umum : .....................................

b. Kesadaran : .....................................

c. Ekspresi wajah : ......................................

d. Berat Badan : ........kg

e. Tinggi badan : ........cm

3. Pemeriksaan tanda-tanda vital

a. Tekanan darah : ...........mmhg

b. Nadi : .........x / menit

c. Suhu : ........ 0C

d. Pernapasan : ..........x / menit

4. Pemeriksaan obstetri (Inspeksi, Palpasi dan Perkusi)

a. Kepala / Rambut

Inspeksi : ..............................................................................................

Palpasi : ..............................................................................................

b. Wajah

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

c. Mata

Inspeksi : ............................................................................................

d. Hidung

Inspeksi : ............................................................................................

Palpasi : ...........................................................................................

e. Telinga

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

f. Mulut dan Gigi

Inspeksi : ............................................................................................

g. Leher

Palpasi : ............................................................................................

h. Payudara

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

i. Abdomen

Inspeksi : ............................................................................................

Palpasi : .........................................................................................

j. Genitalia dan anus

Inspeksi : ............................................................................................

k. Ekstremitas atas/bawah

Inspeksi : ............................................................................................

Palpasi : ............................................................................................

Perkusi : ............................................................................................

ASSESMENT (A)

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PLANNING (P)

Tanggal : ................................................. Jam : .............................................

1. ....................................................................................................................

Hasil :

2. ....................................................................................................................

Hasil :

3. ....................................................................................................................

Hasil :

4. ....................................................................................................................

Hasil :

5. ....................................................................................................................

Hasil :