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Registrasi:
FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM
1.
Kunjungan awal
No. Registrasi
: ..............................................................
Nama Pengkaji
: ..............................................................
Hari/ Tanggal
: ..............................................................
Waktu Pengkajian
: ..............................................................
Tempat Pengkajian
: ..............................................................
Tanda Tangan
:
...........................................
(
)
Data Subjektif
A.
Identitas
Ibu
Suami
Nama
Usia
Agama
Pendidikan
Pekerjaan
Pendapatan
Golongan darah
Suku
Alamat
No. Telepon
1
No. Registrasi:
Transportasi yg
diandalkan
B.
Yang Di Rasakan Ibu:
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
C.
Riwayat Obstetri Lalu
Tahu
Ana
n
kke
Kehamilan
Lama
D.
FE
Persalinan
TT
Bayi
Penolo
Tempa
Jeni
ng
t
s
H/M
JK
Nifas
BB/TB
Riwayat Obstetri Sekarang
1.
Kehamilan
Komplikasi
: ..............................................................
Fe, jika ya berapa banyak yang diminum:.............................
TT, jika Ya jumlah/ terakhir diberikan: .........kali/ ......................
2.
Persalinan
Jenis
Tindakan
: ......................................................... .
:
..............................................................
2
Vit.
A
Menyusu
No. Registrasi:
Penolong
:
..............................................................
Tempat
:
..............................................................
Perdarahan ..........................................................:
...
Komplikasi Ibu
:
..............................................................
Komplikasi
BBL
:
..................................
............................
E.
:
Pengkajian
nifas Saat ini
1.
Lochea
Jumlah
: ..............................................................
Warna
: ..............................................................
Bau
: ..............................................................
2.
Laktasi
Menyusui/ti
dak
:.................
.......................................
....
Frekuensi : ..............................................................
Keluhan
: ..............................................................
3
... - Keluhan : ................................................ Respon ibu terhadap bayi Keluhan 4................... Istirahat : ............ Personal hygiene Cara cebok : ........................................ ............ Keluhan 6................................................. 4 ........ : ................................................... Frekuensi Ganti Pembalut : ...................... - Keluhan - Konsistensi : 5....................... Registrasi: 3.............. Perawatan payudara : ............................................................... - Frekuensi : ............................................................................. : .................................. Eliminasi BAK - Frekuensi : ....... ...........................................................No..................................................... BAB - Sudah BAB : ................................
................ Riwayat Kesehatan (Coret yang tidak perlu............ Perawatan bayi Mandiri atau dibantu : ................. (untuk kunjungan pertama) H............) (Alergi/HIV/Anemia/Syphilis/Hepatitis/TBC/Penyakit ginjal/Jantung/DM/Penyakit kronis/Pernah operasi/Tiroid/Pernah dirawat) Keterangan:……………………………………………………………………… G............................................................................... 5 ..... Pernikahan ke : .................. ......................... Registrasi: 7.... oleh siapa F............ Riwayat Kesehatan Keluarga : .......... Keadaan Psikososial 1....................... Jika dibantu.........No..................................... : ................. Status Pernikahan Ya/Tidak : Lama : .......................
............... 2........................................................................................ 3.................................................................... Adat Istiadat yang berkaitan dengan masa nifas I....................No............... ............. Makan Menu Frekuensi : ................ Registrasi: 2...... Pekerjaan rumah 6 .... 4.......................... Frekuensi : .......... : ............................................................................ Pengambil an Keputusan Keluarga 5................................................................................. Minum Jenis minuman : ........ : ..... Aktivitas Sehari-hari 1........................ Dukungan Keluarga : ..................... Tempat tinggal 3................. : ............................ Pantangan : .................. ............................................................................ : ............. Porsi Pantangan : ..... : .......................................
.....................No.............. 7 ......................................................... Registrasi: Mandiri atau dibantu : .............................. Keadaan Umum Kesadaran : .. ............ Jika dibantu... oleh siapa 4................ : .......................... Gaya Hidup Merokok Minuman Alkohol : : Obat- obatan terlarang : Data Objektif A..........
. kali/menit C............................................... Edema pada wajah : ....................... 2......................... Payudara Bentuk : Kebersihan : ......... a : ............ Kepala dan Leher Sklera Konjungtiv : ........................................................................................................................................................................................................................ Registrasi: B.. Leher : .........No........... kali/menit Pernafasan : ...................................... 8 simetris .............mm/Hg Suhu : .. TandaTanda Vital Tekanan Darah : . ......... Bibir : ..... Pemeriksa an Fisik 1.............................................◦C Nadi : ........................
......................... 5..... Ekstremita s atas Warna ujung kuku : . Registrasi: Keadaan puting : ......... 4........ ........TFU : ......... Kolostrum : ........................................................................................................................................................ Ekstremita s bawah 9 ................................ ........ ......... .................Kontraksi : ............................ Abdomen Luka bekas operasi : .........................No.... Uterus ............................................................................................... 3... Kandung Kemih : .............. ............................. Edema : ......................
.............. Tanda Homan : ............................................. ......................... Oedema Hematoma : ....................... ......................... - Adakah tanda .................................. (bau......... jahitan & luka - Bersih - Kering/bas ah : . 6.. Keadaan : ................................................................................ .......... Genitalia & Anus Kebersihan : ..................................... kemerahan) 10 infeksi : ...................... pus........................................... : ........................................................ Registrasi: Warna ujung kuku : ......... ................................... Refleks pattela : ...........................................................................No..................
........................ - Masalah - Diagnosa : .................................................................................................................No.............................................................. Hemoroid : ............................................................................................ - Kebutuhan Tindakan Segera : .................. Masalah Potensial - : ........................... - Jumlah : .. PENATALAKSANAAN 11 ... Potensial - : .............................................................................. Registrasi: Lochea - Warna : ......... Antisipasi masalah potensial : ........... ANALISA - Diagnosa : .................................................................................... .................................................................... .............................. - Bau : .
................................................. ............. B..................................... Hari/ Tanggal : . Waktu Pengkajian : ........................................... Registrasi: 2... Nama Pengkaji : .............................................................................................. 2.. Yang di Rasakan Ibu ............................................... A......................... Yang dirasakan sejak kunjungan terakhir 12 ................. Registrasi : ................................................................. Tempat Pengkajian : . Perdaraha n Warna : ......................................................... ..................................... Pengkajian nifas sekarang 1...................................................................................................................... Lochea : .......................................................No.......................................................................... Pada 2-6 hari postpartum No....................... Banyaknya : ...............................................................................
................................................................. 3............... Registrasi: Demam Mual muntah Pusing yang hebat Nyeri tungkai Sakit kepala Lain-lain ...................................................................... : ......No...... Minum Jenis minuman : .............. - Keluhan : .................................................................................................... Makan Menu : ............................................................. ............................................................. Masalah 4.................................... : ....................... Porsi : ......................................................... 5...................................................... Pantangan : .... Frekuensi : ..... Respon ibu terhadap bayi sejak kunjungan terakhir Perubahan : .............................................................. 6.................... Frekuensi Pantangan : ................................................................... BAB 13 .............................. Eliminasi BAK - Frekuensi : ................
.......................................... Keluhan : ............................................. 9.................................................................................................................................................................................................................... - Frekuensi : ................................ Laktasi Menyusui/tidak : ......................................................... : ................................................ Frekuensi : ...... Lokia Jumlah : ....................................... Pembalut Perawatan : .................................................... Personal hygiene Cara cebok : ................................................No.. Bau : ........................... Istirahat Tidur siang : ... Registrasi: - Sudah BAB : ........................................................................................... - Keluhan : ................................................ 14 ............ Keluhan 8.......................................................... ASI / PASI : ............... payudara : ................................................................................... Warna : ......... Tidur malam : ... 10.......................................................... 7........
................................................................................. Kebersihan : .. Kepala dan Leher 15 .......................... Registrasi: 11.................... kali/menit 4......................... Kesadaran : ........... Data Objektif A........... 2...................... B......... oleh siapa : ................. TandaTanda Vital 1................. Suhu : ..... : ............. Keadaan Umum 1.................◦C 3.......No............. Pernafasan : ... Keadaan Emosi 3...................................................... Perawatan bayi Mandiri atau dibantu : ........................................................ Nadi : ................... Jika dibantu....... kali/menit 4.................. Pemeriksa an Fisik 1..mm/Hg 2......... Tekanan Darah : .
............................ Kemeraha n : ...............No........................................................................... : ............................................... : .......................................................... Lecet/ luka : ................. .................................. ............... Registrasi: Sklera Konjungtiv a : .................................. Bengkak Nyeri tekan : ................................... Teraba penuh : ................................. .......................................................................................................................................................... Edema pada wajah: ............................................... : ....... Keadaan puting : ........ Payudara Simetris Kebersihan : .. .................................... 16 ...... .................... 2..............
............................................... : ............... Oedema Hematoma : ... ................... Tanda Homan : ................... Registrasi: 3............................................................................................................. Edema 5...................... ... Abdomen Uterus - TFU - kontraksi : ........................ Ekstremita s Bawah Refleks pattela : .............................................. Keadaan jahitan & luka - Bersih : ... 4.............................................................................................................. : ............. : .................................................................................................No.......... Kandung Kemih : ....... Genitalia Kebersihan : .................. 17 .................................... ........................
..................................... 18 .............................. - Masalah : ..............................No............. - Diagnosa Potensial - : .............. - Adakah tanda infeksi : ..................... Hemoroid : ............................................................. : ........................ Lokia - Warna : .......................................................... ................. Anus 7....................... Pemeriksa an penunjang Hb : ......... Registrasi: - Kering/bas ah : .................... - Jumlah : ........................ ANALISA - Diagnosa : .................... - Bau 6............................................................................... Masalah Potensial : .............................................................................. ..................................................
. ........................ Pad a 2 Minggu Postpartum Nama Pengkaji : .......................... PENATALAKSANAAN 3..................................... Yang klien rasakan : ....................... Waktu Pengkajian : ................... ( ) Subjektif A...................................... Hari/ Tanggal : ............................................... Tempat Pengkajian : ............................................ Tanda Tangan : ............................................................. ............................................................................. .....No................................................................................................................................... - Kebutuhan Tindakan Segera : ................................... ............................................................................................. 19 ......... Registrasi: - Antisipasi masalah potensial : .................................................................................................................................................................... ..........................................................
......................................... mual muntah...................................................................................................... Porsi: ....... ......................... ..................................................................................................................... 2..................................... Peng obatan: ............................ Registrasi: ............................................................................................. Masa lah: ..................... Pant angan: ......................................... . Jenis minuman: ............................................................................................................................................................................................................................. Peng kajian nifas saat ini 1..................................... Nutri si ...................... Resp on ibu terhadap bayi sejak kunjungan terakhir .......................................................................................................................... Freku ensi: ...... 4......................................... ............. sakit kepala) ........................................................................................................................................................................................................ ......................................................... pusing yang hebat..................................................................................................................................................................................................................................................... .................................................................................................................................................................................. 3...................................................................................................................................................................................................................................................... Freku ensi: . Hidra si ................. ................................................................. ...................................................................... Menu : .................. B............... Pant angan: ........................ Temp at: ............................................................................................................................... Tand a-tanda bahaya (demam..........................................................................................................................................................................No...................................... nyeri tungkai..................................... .......... Peru bahan: ...................... 20 ...................................................................................................................
................................................. Juml ah: .................... Istira hat .......................................................... Suda h BAB/belum: ..................................................... ........................................................... BAB .................................................................................................................................................................................................... Freku ensi: ............................................................................................................................................................ BAK ......... . ......................... Pers onal hygene ......................................................................... 21 ................................................................... ................................................................................................................................................. Tidur siang: ................................................................................................................................................................................. Registrasi: 5...................................................................................................................... 8................................................................................................................................................................... Lokia ......................................................................................... ................................................................................................................................................................................................................................................................................... Freku ensi: ............................................................................................................................................................................................................................No......................................................................................... .............................. Cara cebok: ................. Pera watan payudara: ................................. 7................... .................................................................... 6.............................. Tidur malam:.................................................. ............................ Masa lah: ....................................................................................... Masa lah: ....................................................................................... Pem balut:................................................................................................................... Elimi nasi ................................................................................................................................. Masa lah: .................. Konsi stensi : .......................................... ......................................
............................................................................................................................................................. Keadaan Umum 22 ...................... Objektif A.................................................................................................................. Renc ana hubungan seksual: ........................................................................................................................................................................................... C................. 4........... Warn a: .................. 5............... Jika dibantu.............................................................................. Registrasi: .................................................................................................................................................................. ........................... ......................................... 10................................................................................................................. oleh siapa:........... Riwayat KB 1.................................. Bau: ............................................................. Keluhan : .............. Rencana KB : ................................................................................................................ 11..................... Efek samping : .................................................................................................................... . ............. Keluh an: ...................................... 2.................................................... Pera watan bayi ............No................................................................................... Meny usui/tidak: .. 6.................................... Lama : .................. 9...................................................... Jenis : ........................................................................................................... Freku ensi: .................................. Lakta si ................................................................................... Mand iri atau dibantu: ................................................................................................................................ Alasan berhenti : ............................................ 3.......................... ........
................................... ............................................. Tanda-tanda vital ............................................................No.... x/menit .......................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................................................... C................................................ ............................................................................. ............................................................................................................... Nadi : ............................................................. Keb ersihan: ...................................... B.. Temp eratur : .......... ............................... .............................................................................................................................Ke simetrisan : ........... Registrasi: .................................................................................. Konju ngtiva Normal Anemis b............................................. 2...................... 23 .................. Teka nan darah : .................................................................................................................... oC ................ mmHg .......... Respi rasi : ..................................................................................................................................................................................................... Skler a: ................................... Kea daan emosi: ............................................................................................................................................................................................................................................................................. Kes adaran: .............................................................................. Eks presi wajah : .......................... .................................................................................. Pem eriksaan Fisik 1....................................................................... ............................... Payu dara .............. Kepal a dan Leher a.
................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ............................ ................................................................................ ...........................Te raba penuh: ........................................................No................................... 5...................................... Registrasi: ......................Be ngkak: ..........Ny erik tekan: ....................................................................Ko ntraksi :.................................................................................................................................................................................................................... Ede ma : ........................................................ Abdomen Uterus/involusi -................................. 24 ........................................ Refle ks Patella: ........................................................... 3................................................... ............ Kebe rsihan:.......................... ................ Tand a Homan: ...............................................................................................................................................................................................................................................................................................................................................Le cet/luka: . Ekstr emitas bawah ............................................................................ ......................................... ........Ke merahan: ........................................................................................................................................................................... .......................................Ke adaan puting susu: . ....Ti nggi Fundus Uteri: .................................................................................... .......................... 4......................Ka ndung kemih: ................................................... Oede ma: ............................................................... Genit alia ............................................................................................................................................................................................................................................................................................................... -......................................................................................................................................................
...................................................................................................... 25 ...... Tand a infeksi: ............................................................... Registrasi: ............ ...................................................... Kead aan jahitan dan luka: ....... - Kebutuhan Tindakan Segera : ............... Kebe rsihan: ................................................................ - Masalah : . Lokia ............................................................................................................................................................................................................................ ........................................................... ANALISA - Diagnosa : ........................................................... . Bau: .............................................................................................................................................................................................. ................... .....................................No............. ........................................................................................................................................................................ ................................................................................................................................................................................................. Antisipasi masalah potensial : ........... Juml ah: ............................................... Kerin g/basah: ............................................................ Warn a: ............. Masalah Potensial - : ............................................ - Diagnosa Potensial - : ...................................................................
........................................................... Peng obatan:............................................................................ Registrasi : ................... .. Waktu Pengkajian : .... Registrasi: PENATALAKSANAAN 4...................................................................................................... Tand a bahaya yang dirasakan sejak kunjungan terakhir ......................................................... Nama Pengkaji : . 26 ..................................... Tanda Tangan : ........................... ......................................................................................................... 2........ ( ) Subjektif 1............ Hari/ Tanggal : ........................................ Pang kajian Nifas Saat Ini a....................................... ............................................................. Tempat Pengkajian : ....................No............................................................................................................................................................................. Yang ibu rasakan ( Adakah penyulit selama nifas ): ......................................................................................................................................................................................................................... ................................................................................... Pada 6 Minggu Postpartum No..................... ...................
.................................................................................................................................................................... Elimi nasi ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Konsi stensi : ........................................................ Jenis minuman: ...................................... .................................................................................................................................................................. ............................................................ Registrasi: ....... .................................................................... d... Bany aknya: ........... ............... ............................. BAB .......................................................................................................................................................................................... ... Freku ensi: ............................................................................................. Porsi: ... Freku ensi: ............................................................................ Menu : ............ Freku ensi: ............................................... ............................ Masa lah: ..................... Pant angan:........................................... Resp on ibu tehadap bayi sejak kunjungan terakhir .......................................No................................................................ ........................................ .............................................................. Keluh an: .......................................................................... Nutri si ......................................................................................... b...... e......................................................................... ........................................................................................... Temp at: .......................................................................................................................................... 27 ........................................................................................................ c..... ... Peru bahan:............................................................................ ........................................................................................ Hidra si .......................................................................................................
... Pers onal hygene ................................................................................................................................................................................ h.................................................... Pera watan payudara: ..................................................................... Istira hat ................... Juml ah: .................................. ............................................... j.......................................................... ........... ................................................................... .................................................................................................. Tidur malam: ...........................................No............................................................................................................. Bau: .......................................................................................................................................................... Tidur siang: ..................................................................................................................................................................... g............................................................ Lokia . Keluh an: .............................. ................................................................................................................................................... i.................................. Warn a: ............... ASI/P ASI : ......... f.......... ............ Keluh an: ........ ..................................... .................................... Pera watan bayi 28 .................................................................. Keluh an: .......................................................................................... ............................................................................................................................................................................................................................. Freku ensi: .................................................................... Freku ensi: .... Registrasi: .............................................................................................................................................. BAK ................................................................................................................................................................................................................................................................................................................................................ .............................................................................. Lakta si ...... .................................. ..............................................................................................................................
.................................................................................................................................................. Kapa n metode tersebut akan dimulai: ............................................................... Tanda-tanda vital Tekanan darah :.....................................................................x/menit C.......................................................... 3.................................................................................................................. Oleh: .................... Ekspresi wajah:............................................................................................................................................ ........mmHg Temperatur :................................................................................... Objektif A................................................ Pem eriksaan Fisik 29 ..................................................... ................ Renc ana hubungan seksual: ................................................. Renc ana KB a... Renc ana metode KB yang akan digunakan: ......... ............................ .............No.......................................... ............................................................................................................... Peru bahan sejak kunjungan terakhir: .oC Nadi :................. Keadaan Umum Kesadaran : ... k............................ b..... B. Kebersihan :........................................................................................ .......... Registrasi: .................................
................................................ ...................... ................................................................... Lecet /luka: ......................................................................................................... Ada tanda bendungan/tidak: ................................................................................................................................................................. Kead aan puting: ... Uteru s ....................... Registrasi: a........................................................... d............... Abdo men ................................. Subin volusi: ............... Skler a:........................................................... .......................... Nyeri tekan: ........... ........................................................................................No................................................................. c............................................... Beng kak: ............................................................................. ............................................................................................................ Kand ung kemih: ........................................................................................................................................................... .............................................................................................................................................. .............................................................. .............................. Kepal a dan leher ................................................................ ................................................................. Tera ba penuh/tidak: .......................................................... ............................................. ................................................................................ Ekstr emitas bawah 30 ..................................................................................................................................................................................................................................................... Konju ngtiva: ...................... ................................ ............................................ Kebe rsihan: ............................................... b.............................. Kem erahan:............................................................................................................................................................................. Payu dara ..........
....................... Warn a: ......................................................................................................... Kead aan jahitan dan luka ............. ANALISA - Diagnosa : .............................................. Lokia :........................................................................................... e... ............................................................... Tand a infeksi: .................................................................. Refle ks Patella: .......................................................................................................................................................................................................................................................... - Bau: .................. Genit alia . ........................................................................................................................................................................................................................................................ .......... Kebe rsihan: ..................... Registrasi: ................ - Masalah : .............................. Kebe rsihan: ................................................................................................................................................................... Tand a Homan: ............................................... Masalah Potensial : .................................................................................... ....................................................... ................................ ............................. Kerin g/basah: ................................................. ............ ........................................ 31 ..................................................................................................... - Diagnosa Potensial - : ............................................................................................... Juml ah: .................................................................................No.............................................
........ Registrasi: - Antisipasi masalah potensial : .... ...... ........................... PENATALAKSANAAN 32 ............................. - Kebutuhan Tindakan Segera : .............................No.......................
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