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

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2. Keluhan Pasien

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3. Riwayat Menstruasi

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4. Riwayat Perkawinan

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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

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b. Penyakit yang pernah/sedang diderita keluarga

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

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Alergi :...................................................................................

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Pola eliminasi BAB BAK

Frekuensi ...................................................................................

Warna ...................................................................................

Bau ...................................................................................

Konsistensi ...................................................................................

Keluhan ....................................................................................

Mobilisasi dan permasalahan :......................................................................

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Keluhan jalan lahir :.......................................................................

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Lochea :.........................................................

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Kodisi pada jalan lahir :.......................................................................

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Pola tidur :...............................................................................................

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Aktifitas :..............................................................................................

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Personal hygine :...............................................................................................

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Kelancaran ASI :...............................................................................................

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Kebiasaan menyusu bayi :...................................................................................

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Pola tidur bayi :...............................................................................................

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11. Kondisi Psiko Sosial Spiritual

Psiko Ibu :...............................................................................................

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Perawatan bayi :...............................................................................................

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Peran suami :..............................................................................................

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Peran keluarga :..............................................................................................

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Hubungan Ibu dengan Lingkungan : ..........................................................

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Spiritual :...............................................................................................

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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

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ASSESMENT

1. Diagnosis Kebidanan

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2. Masalah

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3. Kebutuhan

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4. Diagnosis Potensial

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5. Masalah Potensial

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6. Kebutuhan Tindakan Segera

a. Mandiri :

b. Kolaborasi :

c. Merujuk :

PLANNING

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