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Format Nifas

Format Nifas

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Published by: Sinta Rahma on Dec 23, 2012
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No.

Registrasi:

1

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1. Kunjungan awal
No. Registrasi : ..............................................................
Nama Pengkaji : ..............................................................
Hari/ Tanggal : ..............................................................
Waktu Pengkajian : ..............................................................
Tempat Pengkajian : ..............................................................
Tanda Tangan :

...........................................
( )

Data Subjektif
A. Identitas
Ibu Suami
Nama
Usia
Agama
Pendidikan
Pekerjaan
Pendapatan
Golongan darah
Suku
Alamat
No. Telepon
No. Registrasi:

2

Transportasi yg
diandalkan






B. Yang Di Rasakan Ibu:
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
C. Riwayat Obstetri Lalu
Tahu
n
Ana
kke
Kehamilan Persalinan Bayi Nifas
Lama FE TT
Penolo
ng
Tempa
t
Jeni
s
H/M JK BB/TB
Vit.
A
Menyusui


D. Riwayat Obstetri Sekarang
1. Kehamilan
Komplikasi : ..............................................................
Fe, jika ya berapa banyak yang diminum:.............................
TT, jika Ya jumlah/ terakhir diberikan: .........kali/ ......................
2. Persalinan
 Jenis : ......................................................... .

 Tindakan :
..............................................................
No. Registrasi:

3

 Penolong :
..............................................................
 Tempat :
..............................................................
 Perdarahan .......................................................... :
...
 Komplikasi Ibu :
..............................................................
 Komplikasi
BBL :
..................................
............................ :
E. Pengkajian
nifas Saat ini
1. Lochea
 Jumlah : ..............................................................
 Warna : ..............................................................
 Bau : ..............................................................
2. Laktasi
 Menyusui/ti
dak
:.................
.......................................
....
 Frekuensi : ..............................................................
 Keluhan : ..............................................................
No. Registrasi:

4

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

5

7. Perawatan
bayi
 Mandiri
atau dibantu :
.......................................
.......................
 Jika
dibantu, oleh siapa : ..............................................................

F. Riwayat
Kesehatan
(Coret yang tidak perlu.)

(Alergi/HIV/Anemia/Syphilis/Hepatitis/TBC/Penyakit
ginjal/Jantung/DM/Penyakit kronis/Pernah operasi/Tiroid/Pernah dirawat)
Keterangan:………………………………………………………………………

G. Riwayat
Kesehatan Keluarga : ..............................................................
(untuk kunjungan pertama)
H. Keadaan
Psikososial
1. Status
Pernikahan
 Ya/Tidak :
 Lama : ..............................................................
 Pernikahan
ke : ..............................................................
No. Registrasi:

6

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

7

 Mandiri
atau dibantu :
.......................................
.......................
 Jika
dibantu, oleh siapa : ..............................................................
4. Gaya
Hidup
 Merokok :
 Minuman
Alkohol :
 Obat-
obatan terlarang :








Data Objektif
A. Keadaan
Umum
 Kesadaran : ..............................................................

No. Registrasi:

8

B. Tanda-
Tanda Vital
 Tekanan
Darah : ...................................mm/Hg
 Suhu : ...................................◦C
 Nadi : ................................... kali/menit
 Pernafasan : ................................... kali/menit

C. Pemeriksa
an Fisik
1. Kepala dan
Leher
 Sklera : ..............................................................
 Konjungtiv
a : ..............................................................
 Bibir : ..............................................................
 Leher : ..............................................................
 Edema
pada wajah :
.......................................
.......................

2. Payudara
 Bentuk : simetris asimetris
 Kebersihan : ..............................................................
No. Registrasi:

9

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

10

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

11

 Lochea
- Warna : ..............................................................
- Jumlah : ..............................................................
- Bau : ..............................................................
 Hemoroid : ..............................................................
ANALISA
- Diagnosa : ..............................................................
- Masalah : ..............................................................
- Diagnosa
Potensial : ..............................................................
- Masalah
Potensial : ..............................................................
- Antisipasi
masalah potensial :
............................................................
..
- Kebutuhan
Tindakan Segera :
............................................................
..

PENATALAKSANAAN



No. Registrasi:

12





2. Pada 2-6
hari postpartum
No. Registrasi : ..............................................................
Nama Pengkaji : ..............................................................
Hari/ Tanggal : ..............................................................
Waktu Pengkajian : ..............................................................
Tempat Pengkajian : ..............................................................

A. Yang di
Rasakan Ibu
................................................................................................................
................................................................................................................
................................................................................................................

B. Pengkajian
nifas sekarang
1. Perdaraha
n
 Warna : ..............................................................
 Lochea : ..............................................................
 Banyaknya : ..............................................................
2. Yang dirasakan sejak kunjungan terakhir
No. Registrasi:

13

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

14

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

15

11. Perawatan
bayi
 Mandiri
atau dibantu : ..............................................................
 Jika
dibantu, oleh siapa : ..............................................................
Data Objektif
A. Keadaan
Umum
1. Kesadaran : ..............................................................
2. Keadaan
Emosi : ..............................................................
3. Kebersihan : ..............................................................

B. Tanda-
Tanda Vital
1. Tekanan Darah : ...................................mm/Hg
2. Suhu : ...................................◦C
3. Nadi : ................................... kali/menit
4. Pernafasan : ................................... kali/menit

4. Pemeriksa
an Fisik
1. Kepala dan
Leher
No. Registrasi:

16

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

17

3. Abdomen
 Uterus
- TFU : ..............................................................
- kontraksi : ..............................................................
 Kandung
Kemih :
................................
..............................
4. Ekstremita
s Bawah
 Refleks
pattela :
..................................
............................
 Tanda
Homan :
..................................
............................
 Edema : ..............................................................
5. Genitalia
 Kebersihan : ..............................................................
 Oedema : ..............................................................
 Hematoma : ..............................................................
 Keadaan jahitan & luka

- Bersih : ..............................................................
No. Registrasi:

18

- Kering/bas
ah :
...........................
...........................
........
- Adakah
tanda infeksi : ..............................................................
 Lokia
- Warna : ..............................................................
- Jumlah : ..............................................................
- Bau : ..............................................................
6. Anus
 Hemoroid : ..............................................................
7. Pemeriksa
an penunjang
 Hb : .............................................................. :

ANALISA
- Diagnosa : ..............................................................
- Masalah : ..............................................................
- Diagnosa
Potensial : ..............................................................
- Masalah
Potensial : ..............................................................
No. Registrasi:

19

- Antisipasi
masalah potensial :
............................................................
..
- Kebutuhan
Tindakan Segera :
............................................................
..





PENATALAKSANAAN
3. .......................................................................................................... Pad
a 2 Minggu Postpartum
Nama Pengkaji : ................................................................................
Hari/ Tanggal : ................................................................................
Waktu Pengkajian : ...............................................................................
Tempat Pengkajian : ...............................................................................
Tanda Tangan :

...........................................
( )


Subjektif
A. ............................................................................................................ Yang
klien rasakan : ...................................................................................
..........................................................................................................
No. Registrasi:

20

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

21

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

22

 ................................................................................................ Warn
a: .........................................................................................
 ................................................................................................ Bau:
............................................................................................
9. .................................................................................................... Lakta
si
 ................................................................................................ Meny
usui/tidak: ............................................................................
 ................................................................................................ Freku
ensi: .....................................................................................
 ................................................................................................ Keluh
an: .......................................................................................
10. .................................................................................................. Pera
watan bayi
 ................................................................................................ Mand
iri atau dibantu: ....................................................................
 ................................................................................................ Jika
dibantu, oleh siapa: ..............................................................
11. .................................................................................................. Renc
ana hubungan seksual: ............................................................
.................................................................................................
C. Riwayat KB
1. Jenis : ..............................................................
2. Lama : ..............................................................
3. Efek samping : ..............................................................
4. Alasan berhenti : ..............................................................
5. Keluhan : ..............................................................
6. Rencana KB : ..............................................................

Objektif
A. Keadaan Umum
No. Registrasi:

23

 .......................................................................................................... Kes
adaran: ..........................................................................................
 .......................................................................................................... Eks
presi wajah : ..................................................................................
 .......................................................................................................... Keb
ersihan: .........................................................................................
 .......................................................................................................... Kea
daan emosi: ...................................................................................

B. Tanda-tanda vital
 ..................................................................................................... Teka
nan darah : ........................................................................ mmHg
 ..................................................................................................... Temp
eratur : .............................................................................
o
C
 ..................................................................................................... Nadi
: .......................................................................................... x/menit
 ..................................................................................................... Respi
rasi : .............................................................................

C. ........................................................................................................... Pem
eriksaan Fisik
1. ...................................................................................................... Kepal
a dan Leher
a. ................................................................................................ Konju
ngtiva
Normal Anemis
b. ................................................................................................ Skler
a: ..........................................................................................
2. ...................................................................................................... Payu
dara
 ...................................................................................................... Ke
simetrisan : ................................................................................
No. Registrasi:

24

 ...................................................................................................... Ke
adaan puting susu: ....................................................................
 ...................................................................................................... Le
cet/luka: .....................................................................................
 ...................................................................................................... Ke
merahan: ...................................................................................
 ...................................................................................................... Be
ngkak: ........................................................................................
 ...................................................................................................... Ny
erik tekan: ..................................................................................
 ...................................................................................................... Te
raba penuh: ...............................................................................

3. Abdomen
 Uterus/involusi
- .............................................................................................. Ti
nggi Fundus Uteri: ............................................................
- .............................................................................................. Ko
ntraksi : .............................................................................
 ..................................................................................................... Ka
ndung kemih: ............................................................................
4. ..................................................................................................... Ekstr
emitas bawah
 ................................................................................................ Refle
ks Patella: ............................................................................
 ................................................................................................ Tand
a Homan: .............................................................................
 ................................................................................................ Ede
ma : ....................................................................................
5. ...................................................................................................... Genit
alia
 ................................................................................................ Kebe
rsihan: ..................................................................................
 ................................................................................................ Oede
ma: ......................................................................................
No. Registrasi:

25

 ................................................................................................ Kead
aan jahitan dan luka:
- .......................................................................................... Kebe
rsihan: ...........................................................................
- .......................................................................................... Kerin
g/basah: ........................................................................
- .......................................................................................... Tand
a infeksi: .......................................................................
 ................................................................................................ Lokia
- .......................................................................................... Warn
a: ..................................................................................
- .......................................................................................... Juml
ah: ................................................................................
- .......................................................................................... Bau:
.....................................................................................

ANALISA
- Diagnosa : ..............................................................
- Masalah : ..............................................................
- Diagnosa
Potensial : ..............................................................
- Masalah
Potensial : ..............................................................
- Antisipasi
masalah potensial :
............................................................
..
- Kebutuhan
Tindakan Segera :
............................................................
..
No. Registrasi:

26


PENATALAKSANAAN


4. Pada 6 Minggu Postpartum
No. Registrasi : ................................................................................
Nama Pengkaji : ................................................................................
Hari/ Tanggal : ................................................................................
Waktu Pengkajian : ...............................................................................
Tempat Pengkajian : ..............................................................................
Tanda Tangan :

...........................................
( )


Subjektif
1. ............................................................................................................ Yang
ibu rasakan ( Adakah penyulit selama nifas ): ...................................
..........................................................................................................
..........................................................................................................
2. ............................................................................................................ Pang
kajian Nifas Saat Ini
a. ....................................................................................................... Tand
a bahaya yang dirasakan sejak kunjungan terakhir
 ............................................................................................ Peng
obatan: .............................................................................
No. Registrasi:

27

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

28

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

29

 ............................................................................................ Oleh:
........................................................................................
 ............................................................................................ Peru
bahan sejak kunjungan terakhir: ......................................
k. ....................................................................................................... Renc
ana hubungan seksual: ...............................................................
3. ............................................................................................................ Renc
ana KB
a. ....................................................................................................... Renc
ana metode KB yang akan digunakan: ........................................
b. ....................................................................................................... Kapa
n metode tersebut akan dimulai: ..................................................




Objektif
A. Keadaan Umum
 Kesadaran :
............................................................................
 Ekspresi
wajah:...........................................................................
 Kebersihan
:............................................................................

B. Tanda-tanda vital
 Tekanan darah :..............mmHg
 Temperatur
:..............
o
C
 Nadi
:..............x/menit

C. ..................................................................................................... Pem
eriksaan Fisik
No. Registrasi:

30

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

31

 ....................................................................................... Refle
ks Patella: ..................................................................
 ....................................................................................... Tand
a Homan: ...................................................................
e. ................................................................................................. Genit
alia
 ....................................................................................... Kebe
rsihan: ........................................................................
 ....................................................................................... Kead
aan jahitan dan luka
- ................................................................................. Kerin
g/basah: ...............................................................
- ................................................................................. Kebe
rsihan: ..................................................................
- ................................................................................. Tand
a infeksi: ..............................................................
 ........................................................................................ Lokia
:.....................................................................................
- ................................................................................. Juml
ah: .......................................................................
- ................................................................................. Warn
a: .......................................................................
- Bau: ........................................................................

ANALISA
- Diagnosa : ..............................................................
- Masalah : ..............................................................
- Diagnosa
Potensial : ..............................................................
- Masalah
Potensial : ..............................................................
No. Registrasi:

32

- Antisipasi
masalah potensial :
............................................................
..
- Kebutuhan
Tindakan Segera :
............................................................
..

PENATALAKSANAAN




No. Registrasi:

Transportasi yg diandalkan

B.

Yang Di Rasakan Ibu: ..................................................................................................................... ..................................................................................................................... .....................................................................................................................

C. Kehamilan Lama FE

Riwayat Obstetri Lalu Persalinan TT Penolo ng Tempa t Jeni s H/M Bayi JK BB/TB Vit. A Nifas

Tahu n

Ana kke

Menyusu

D. 1.

Riwayat Obstetri Sekarang Kehamilan Komplikasi : ..............................................................

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

Tindakan .............................................................. 2

:

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