No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

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



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



Keluhan

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

3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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