No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

Nama Pengkaji

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Hari/ Tanggal

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Waktu Pengkajian

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

Tempat Pengkajian

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

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

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

:

..............................................................
2

Vit.
A

Menyusu

No. Registrasi:

Penolong

:

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Tempat

:

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Perdarahan ..........................................................:
...

Komplikasi Ibu

:

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Komplikasi
BBL

:

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

:

Pengkajian
nifas Saat ini
1.

Lochea

Jumlah

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

Warna

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

Bau

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

2.

Laktasi

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

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

Keluhan

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

3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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