No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

Nama Pengkaji

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

Hari/ Tanggal

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Waktu Pengkajian

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

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

:

..................................
............................
E.

:

Pengkajian
nifas Saat ini
1.

Lochea


Jumlah

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



Warna

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



Bau

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

2.

Laktasi


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



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



Keluhan

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

3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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