No.

Registrasi:

FORMAT PENGKAJIAN ASUHAN KEBIDANAN
PADA IBU POSTPARTUM

1.

Kunjungan awal
No. Registrasi

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

Nama Pengkaji

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

Hari/ Tanggal

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

Waktu Pengkajian

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

Tempat Pengkajian

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

Tanda Tangan

:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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