No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

Nama Pengkaji

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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

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

:

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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

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

........... Riwayat Kesehatan Keluarga : ... 5 ................... ......... 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.........  Jika dibantu................................................No...........................  Pernikahan ke : ..................................................... Registrasi: 7............................................ Status Pernikahan  Ya/Tidak :  Lama : ...... Keadaan Psikososial 1........... (untuk kunjungan pertama) H...... oleh siapa F................................................ Perawatan bayi  Mandiri atau dibantu : . : ..................

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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