No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

Nama Pengkaji

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

Hari/ Tanggal

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Waktu Pengkajian

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Tempat Pengkajian

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Tanda Tangan

:

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(

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Data Subjektif
A.

Identitas
Ibu

Suami

Nama
Usia
Agama
Pendidikan
Pekerjaan
Pendapatan
Golongan darah
Suku
Alamat
No. Telepon

1

No. Registrasi:

Transportasi yg
diandalkan

B.

Yang Di Rasakan Ibu:
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C.

Riwayat Obstetri Lalu

Tahu

Ana

n

kke

Kehamilan
Lama

D.

FE

Persalinan
TT

Bayi

Penolo

Tempa

Jeni

ng

t

s

H/M

JK

Nifas
BB/TB

Riwayat Obstetri Sekarang
1.

Kehamilan
Komplikasi

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

Fe, jika ya berapa banyak yang diminum:.............................
TT, jika Ya jumlah/ terakhir diberikan: .........kali/ ......................
2.

Persalinan

Jenis

Tindakan

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

:

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

Vit.
A

Menyusu

No. Registrasi:

Penolong

:

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Tempat

:

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Perdarahan ..........................................................:
...

Komplikasi Ibu

:

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Komplikasi
BBL

:

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E.

:

Pengkajian
nifas Saat ini
1.

Lochea

Jumlah

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

Warna

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

Bau

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

2.

Laktasi

Menyusui/ti
dak
:.................
.......................................
....

Frekuensi : ..............................................................

Keluhan

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

3

................................. 4 ........................  Frekuensi Ganti Pembalut  : ................... : ................. BAB - Sudah BAB : ............................................ Perawatan payudara : ............................................................... Keluhan 6.......................................................................... Personal hygiene  Cara cebok : ............ Registrasi: 3....................................................... Eliminasi  BAK - Frekuensi : ............No...................................................... .................... - Frekuensi : ...................................................................... Istirahat : .... : ........................ Respon ibu terhadap bayi  Keluhan 4......................... - Keluhan  : ............................................................ .............. - Keluhan - Konsistensi : 5..

......................... Perawatan bayi  Mandiri atau dibantu : ............... Status Pernikahan  Ya/Tidak :  Lama : ..... Registrasi: 7....  Jika dibantu....... Riwayat Kesehatan Keluarga : ....................... oleh siapa F....... Riwayat Kesehatan (Coret yang tidak perlu............................................................... : ................... ......  Pernikahan ke : ............................................................. Keadaan Psikososial 1.........................No... (untuk kunjungan pertama) H............. 5 .......................) (Alergi/HIV/Anemia/Syphilis/Hepatitis/TBC/Penyakit ginjal/Jantung/DM/Penyakit kronis/Pernah operasi/Tiroid/Pernah dirawat) Keterangan:……………………………………………………………………… G....................

.No....... : ... Dukungan Keluarga : ............ Pekerjaan rumah 6 ......... : .............. 2............................ Registrasi: 2......... 3.................................................................................. 4............................................................. ................................. Aktivitas Sehari-hari 1.............. Tempat tinggal 3........................................ Makan  Menu  Frekuensi : ..... Adat Istiadat yang berkaitan dengan masa nifas I...........................................................  Frekuensi : ..... : .... ............... Minum  Jenis minuman : .... : ......................................................................................................................................  Porsi  Pantangan : ......... : ......................................................................................... Pengambil an Keputusan Keluarga 5.........................  Pantangan : ..............................

....................................... : ......................  Jika dibantu.... oleh siapa 4............ Registrasi:  Mandiri atau dibantu : ...No........... 7 ...... ............................................................... Gaya Hidup  Merokok  Minuman Alkohol  : : Obat- obatan terlarang : Data Objektif A.. Keadaan Umum  Kesadaran : .............................

...................................................mm/Hg  Suhu : ................... Pemeriksa an Fisik 1..... TandaTanda Vital  Tekanan Darah : ................................................ kali/menit  Pernafasan : ...............  Edema pada wajah : ................. Kepala dan Leher  Sklera  Konjungtiv : ............. ..........................No....................... a : .................................................................................................................................................... 2.................◦C  Nadi : ........... Registrasi: B.... kali/menit C.... Payudara  Bentuk :  Kebersihan : .......  Leher : .................................................. 8 simetris .....  Bibir : .............................

................ ...No............ ...................................TFU : ..... 4........................................................... Ekstremita s atas  Warna ujung kuku : ........................................................  Kolostrum : .............................  Uterus ........................................... Edema : ........Kontraksi : ........................... Abdomen  Luka bekas operasi : ............................. ....  5................... Ekstremita s bawah 9 ....... ........... 3.................................... Registrasi:  Keadaan puting : ...........................................................................  Kandung Kemih : .... .........................

...................................................... kemerahan) 10 infeksi : .............. Genitalia & Anus  Kebersihan : . - Adakah tanda ........... ............. Registrasi:  Warna ujung kuku : ........................ : ..............................  Refleks pattela : ............ ...................................... ......... pus.............................................................. jahitan & luka - Bersih - Kering/bas ah : ..............................................................................................  Keadaan : ............. ..................................................................................................................  Oedema  Hematoma : .............................................No..... 6.... (bau...  Tanda Homan : .................

..................................................................................................... - Jumlah : .. - Masalah - Diagnosa : ................... ........................................................................... Potensial - : ...............................  Hemoroid : ... ANALISA - Diagnosa : . - Bau : .No......................................................... - Kebutuhan Tindakan Segera : ...................................................... Masalah Potensial - : ......... PENATALAKSANAAN 11 ...... Antisipasi masalah potensial : ........................................................................................................... ............. Registrasi:  Lochea - Warna : ...............................................................................................................................................

.............................................. 2........................ A...............................................................................................................................................  Lochea : .................................................................................. Tempat Pengkajian : .... B........ Waktu Pengkajian : ...............................................  Banyaknya : ............... Hari/ Tanggal : .............................................................................................. Nama Pengkaji : ..................................................... Pengkajian nifas sekarang 1............... ...................................................... Registrasi: 2..................................... Perdaraha n  Warna : ..................................................... Pada 2-6 hari postpartum No.............................. ............. Yang dirasakan sejak kunjungan terakhir 12 ...............................................................................No...................... Registrasi : ............... Yang di Rasakan Ibu ......

... Minum  Jenis minuman : ................................................................................................................................................................................................................................................................. 3........................................................................ 6........... - Keluhan : .....  Frekuensi : ..............  Porsi : . Registrasi: Demam Mual muntah Pusing yang hebat Nyeri tungkai Sakit kepala Lain-lain ................. ......... : ................................................................................................................................ Eliminasi   BAK - Frekuensi : .............................  Frekuensi  Pantangan : .... BAB 13 ................................. Makan  Menu : .......  Masalah 4.. Respon ibu terhadap bayi sejak kunjungan terakhir  Perubahan : ................................... 5.....No.................................................... : .......................  Pantangan : .................................................................

.................  ASI / PASI : .... Istirahat  Tidur siang : ............................................................................................................. 9.................................................................................. 10........................... - Keluhan : .......... Registrasi: - Sudah BAB : .................... Lokia  Jumlah : ........................................................................................................................................................................  Warna : ........................... - Frekuensi : .  Frekuensi : ..No..............................................................................  Tidur malam  : .............................................................. 14 ........................................................  Pembalut  Perawatan : .......................  Keluhan : ........................... 7...................................................... Keluhan 8........................ Personal hygiene  Cara cebok : .  Bau : ......... Laktasi  Menyusui/tidak : ............................................................................................... : ............................................ payudara : ..........................................................

.................................. Kesadaran : ................................ Nadi : .... Jika dibantu.......................... Kebersihan : ............. B..................... Suhu : .................... Keadaan Emosi 3. : .........◦C 3.... Registrasi: 11.............................. Tekanan Darah : ............ Pemeriksa an Fisik 1........................ Pernafasan : .........mm/Hg 2............................................. Data Objektif A.. kali/menit 4........................................................................ TandaTanda Vital 1.. Keadaan Umum 1.....................No................. kali/menit 4....... 2........ Kepala dan Leher 15 ......... oleh siapa : ............ Perawatan bayi  Mandiri atau dibantu  : ...............................

..............  Kemeraha n : ............................................................................. ......................... : .... 2..................................................... Registrasi:  Sklera  Konjungtiv a : ............... : ............................................ 16 ....................................................................... ..........................................................................  Bengkak  Nyeri tekan : .............................................. ................  Lecet/ luka : ............................................................ ..............  Keadaan puting : ....No... : ...................  Teraba penuh : ............................... Payudara  Simetris  Kebersihan : ...........................................  Edema pada wajah: ................................................... .....................

..................................................................  Tanda Homan : ..  Oedema  Hematoma : .......................... .................................... : ...............No............................................................................... ........................................... : . 4.............................................................. ....................................................................................................... Abdomen  Uterus - TFU - kontraksi  : .......................  Edema 5..... : .......... Genitalia  Kebersihan : ...................... Kandung Kemih : ........................................ Ekstremita s Bawah  Refleks pattela : ..................................  Keadaan jahitan & luka - Bersih : ............................... Registrasi: 3.................. 17 .........

......................... ................................................................................... - Adakah tanda infeksi  : ..................................................................... - Jumlah : ..................................................................................... - Masalah : ............ 18 ......................................... Pemeriksa an penunjang  Hb : ........... Registrasi: - Kering/bas ah : ............ ANALISA - Diagnosa : .... Lokia - Warna : .....................................No................... ................................................ Anus  7................................................................... Masalah Potensial : ..... - Diagnosa Potensial - : ........ - Bau 6................ : ................................................ Hemoroid : ..................

........................ Pad a 2 Minggu Postpartum Nama Pengkaji : .......................................... PENATALAKSANAAN 3.............................. ....................................................... Yang klien rasakan : .......No............................................................................................... Tempat Pengkajian : ... ................................... Tanda Tangan : .................................. ...................................................................................................................................... ( ) Subjektif A............................................. .................... Registrasi: - Antisipasi masalah potensial : .................................................................................................................................................................... Waktu Pengkajian : ........................................... Hari/ Tanggal : ................... - Kebutuhan Tindakan Segera : ............................ 19 ................................................................................................................. .

.............No.. Freku ensi: ............ B........................................................................................ mual muntah................................................................................................................................................................................................................................................................................................ Masa lah: ................................................... Nutri si  ............................ Porsi: ........................................................................................................................................................................................................................................................................ Tand a-tanda bahaya (demam..................... Hidra si  ...................................................... 3............................................................... Pant angan: ............................................................... ......................................................................... Freku ensi: ..................................................................................................................................  ................................... 2............................................ Pant angan: ........ sakit kepala)  ..................... Temp at: .................  ........................................................ Menu : ..............................................................................................................................  ...................................... nyeri tungkai.......................................... Peru bahan: .............................................. Jenis minuman: .................................................................................................................................................................................... 4.......................................................  ...................................................................................  ............. Peng obatan: .................................................................................................................................. ..................................................  .............................................. pusing yang hebat....................................... Resp on ibu terhadap bayi sejak kunjungan terakhir  ......................... 20 .......................... Peng kajian nifas saat ini 1........................................................................................................................................................................................................... Registrasi: .........................................................................................................................................................  ............................................

.......................................................................... Juml ah: ............................................................................................................. Lokia  ............... .............................................................................................................................................................................. 8........................................................................................................................ Elimi nasi  .......................................................................................................................................No...................  .................................................................................................................................. ............................ Masa lah: ............................................................ Masa lah: ............... Tidur malam:...................... Cara cebok: ......... Tidur siang: ..............................................................................................................................................................  ............................................................................................................................... Freku ensi: . Istira hat  ............................................................ Suda h BAB/belum: ................................ Pers onal hygene  .......................... Registrasi: 5................................................................................................. Freku ensi: ........................................................................................................................................................................................................................................................ ............................................................................................................................  ................................................ Masa lah: ................................................................................................................................................... 7....  ........................................ BAK ............................................................................................................................................... Pera watan payudara: ..................... 21 ..................................................................................................................................... Pem balut:......................................................................................................................................  ........................... BAB .......................................................................................................................................... ...................... Konsi stensi : ............... 6..................................................................................................................................................................................

.... Freku ensi: ............................................................................................................... Jika dibantu..................................................... 4......................................................................... Jenis : ........................................ C.................................................... Lakta si  ............................................................................. Bau: ............................................................ Mand iri atau dibantu: ............................. 5.......................................................................................................................................................................... 10.......................................................................................... Riwayat KB 1....................................................................................... Efek samping : ..................................... Warn a: .. Keadaan Umum 22 ...............................................................................................  ...................................................................................................... Alasan berhenti : .......................................... oleh siapa:.......... Lama : .... ............................................ Keluh an: ..........................................  ..............................................................................................................................  .....No...... 3...........................................................................  .. Meny usui/tidak: ..................... 2.................................................................................................................................................................. Pera watan bayi  .......................................................................... Renc ana hubungan seksual: .......... 9. 6......... Keluhan : ................. Objektif A............................................................. Registrasi:  ................................. Rencana KB : ......................................................................................................... 11...........................................................................................................................................

................................................................................................ Pem eriksaan Fisik 1............................................................................... x/menit  .................................... Tanda-tanda vital  ....................................................................................................................................................  .............................................................................................................................................................................................................................................................. Payu dara  ............................................................................................................................................................................................ 23 ... Keb ersihan: ................................................................................................................................................................ Teka nan darah : ................................. Kea daan emosi: ............................................................Ke simetrisan : ........................................................................................................... ................................................................................................................................................... ....  ..................... Nadi : .......................................................................................................................................................... Kes adaran: ...................................................................... B....... Konju ngtiva Normal Anemis b..... ................... Registrasi:  .................. .......................... oC  ..... 2...........................................No.................. mmHg  .......... C.................... ....................................................................................................................................... Temp eratur : .....  ............................................................................................................................................................................................. Respi rasi : ............................ Skler a: .............................................................................................................................. Kepal a dan Leher a........... Eks presi wajah : ..............................................

......................  ........................Ke adaan puting susu: ............................................................................. Kebe rsihan:.........................................................  ................................................................................................................. ........................................Ti nggi Fundus Uteri: ...........................................................................................................................  ......................................  .........Te raba penuh: ...........................................................  .................................. Abdomen  Uterus/involusi -......................................................................................Ke merahan: .......................................................................................................Ko ntraksi :..............No......................................................................................................................  ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Oede ma: ................................................... Refle ks Patella: .......................... Tand a Homan: ............................ 4.........................................................................  ................................................................................. -......Ny erik tekan: .................................... 24 .............................................................................................................Le cet/luka: ................................................................................................................................................................................. 3....................................................................................................................... ..................................................................... 5..  .......... Ekstr emitas bawah  ..............Be ngkak: ..................................................................................................................................................................................  ............................................ Registrasi:  ... Ede ma : ............................................................................................Ka ndung kemih: ...................................... Genit alia  ..............................................................

.............................................................................................. Warn a: ............................................................................................. ................... ...................................................................................................................................... Masalah Potensial - : .............................................................................................................. Kebe rsihan: ................................................................................ ................................ - Kebutuhan Tindakan Segera : .............................................. - Diagnosa Potensial - : ......  ..................... Antisipasi masalah potensial : .......................................................................... Bau: ....................................................................................................................................................No........................... ANALISA - Diagnosa : ................................... Registrasi:  ........................................................................ Kerin g/basah: ............................................................................................................................... 25 ..................................... Kead aan jahitan dan luka: ........................ ...... ......... Lokia ................................................ Tand a infeksi: ........................................................ Juml ah: ...................................................................................................................................................... - Masalah : ........... ..................................................................

....................................................................................................................... ............................................................. Peng obatan:............ ....................................... 26 ......................................................................................................................................................... Hari/ Tanggal : .................................... Pang kajian Nifas Saat Ini a................................ Yang ibu rasakan ( Adakah penyulit selama nifas ): ........................................ Tand a bahaya yang dirasakan sejak kunjungan terakhir  ............................ Tempat Pengkajian : ............ Nama Pengkaji : . 2.............................................................................................................................................. ..... Registrasi: PENATALAKSANAAN 4...................................................................... Registrasi : ........... ........................ Tanda Tangan : .....................................................................................................................No..................... ( ) Subjektif 1........................................................................................................................................................ ......................... Pada 6 Minggu Postpartum No....................... Waktu Pengkajian : ...........................................................

................................................. ..................................................................................................................... Elimi nasi  ............................................................................................................................................................No........................................................................................................................................................................ c.................................. Hidra si  .................................................................. Jenis minuman: ... b.  .......... ....................................... Freku ensi: ................................................................. Pant angan:................................................................................................. ................................... Freku ensi: .........................................................................................  ........................................... Freku ensi: ............................. Registrasi:  ........................................................................................................................ e................................................................... Nutri si  .................................................................................................................................................................................................................................................................. BAB ................................................................................................................................................................................................... Menu : ............... Temp at: .......................................................................................................... Resp on ibu tehadap bayi sejak kunjungan terakhir  ..........  ........... Keluh an: ...........................................................................................................................................................................................................................................................................................................  .................................... .............................. d................................................................................................................................................................ 27 .................................. Bany aknya: .....................  .........................................................................................................................  ...................... Peru bahan:...................... Masa lah: .............................................................. Porsi: .................... .............................. Konsi stensi : ........................................................................................... .........

................................................................................................................................. Juml ah: .............................................  ................................................................................... f.............................................................................. Pers onal hygene  ................ Lakta si  .................................................................................................................................................................................................................................... j........................................................................................................................................................................................ ................................................................................................................ .................................................................................................................................................................................. Bau: ......................................................................................................................................................................................................................................................... h...................................................................................  .........................  ........................................................................................................................... Tidur siang: .......................... ................................................................................  ........................................ Registrasi:  ............................................ ................ Freku ensi: ...................................................................................... i......... ........No.................................................................................. Istira hat  ................... Keluh an: ...... Keluh an: ................................. Keluh an: ............. ..............................................................  ................................................................................ Freku ensi: .................................  .................. Lokia  ................................................................................................................... ASI/P ASI : .................................... Pera watan bayi 28 ............ Warn a: .............................. g.................................................................................................................. BAK ...................................................................................................................................................... Pera watan payudara: ........................ Tidur malam: ......

.................. Oleh: ................................................................................................ .................................................. ..................................................................................................................No............................................ B............................................................. Renc ana hubungan seksual: ....... 3................................. Pem eriksaan Fisik 29 .................................................... Registrasi:  .......................... Keadaan Umum  Kesadaran : ................. Objektif A.................................... Tanda-tanda vital  Tekanan darah :................................................... Renc ana KB a...........  Kebersihan :........ Peru bahan sejak kunjungan terakhir: ............ Renc ana metode KB yang akan digunakan: ..............................  Ekspresi wajah:.....................................................................mmHg  Temperatur :................................... k.................................................................................................. Kapa n metode tersebut akan dimulai: .............................................................................................................oC  Nadi :........................ ........x/menit C...... b......................................................................................................... ..........  ......................................................................................................... ........................

................................................................. Kand ung kemih: ........................................................................................  .................................................................................  ....................................................................................................  ................................. Ekstr emitas bawah 30 ..............  ................................................... Lecet /luka: ....... ....................................................................... Kepal a dan leher  ................................................  .................. Kead aan puting: ............................................................................... Ada tanda bendungan/tidak: .......................................... Konju ngtiva: .............................................................................................................................................. Uteru s  ........... Kem erahan:...............No.................................. Nyeri tekan: .. Payu dara  .  ....  .................................................................................................................................................................................................................. Abdo men  .................................................................................. Tera ba penuh/tidak: ........................................ c................................................................................................................... d...................................................................................................................... b.............................. Kebe rsihan: ................................................... Beng kak: ..................................... Registrasi: a.................................................................................... .............................................. .......................................................................................  ................................................................................................................................................................................................................................................ ................  ............................................................................................................................................................................................. Skler a:.................................................................................. Subin volusi: ...

...................... Kebe rsihan: ............................................................................................................................. - Bau: ........................................................................................................................ Tand a Homan: ...................................No...................................... Kerin g/basah: ................... Juml ah: ........  ...................... Registrasi:  ........................................................................... Masalah Potensial : ............ ............................................................................................................................................... Warn a: ............................................................................................................  ..  ....................................................................................................................................................... Kead aan jahitan dan luka ............................................................ Lokia :..................................................................................................... Kebe rsihan: ........... Tand a infeksi: ............................ Refle ks Patella: ..................................................................................... - Diagnosa Potensial - : ..................................................................................................................................... ............................................................................................................. ................... - Masalah : .............. 31 .............................................................................................................................................................................. ANALISA - Diagnosa : ................................ ...... ................................................................................................................. e................................................... Genit alia  .....................

....................... - Kebutuhan Tindakan Segera : .................. .......No..................................... PENATALAKSANAAN 32 ....... ............ Registrasi: - Antisipasi masalah potensial : ......................

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