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

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Tempat Pengkajian

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Tanda Tangan

:

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(

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Data Subjektif
A.

Identitas
Ibu

Suami

Nama
Usia
Agama
Pendidikan
Pekerjaan
Pendapatan
Golongan darah
Suku
Alamat
No. Telepon

1

No. Registrasi:

Transportasi yg
diandalkan

B.

Yang Di Rasakan Ibu:
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C.

Riwayat Obstetri Lalu

Tahu

Ana

n

kke

Kehamilan
Lama

D.

FE

Persalinan
TT

Bayi

Penolo

Tempa

Jeni

ng

t

s

H/M

JK

Nifas
BB/TB

Riwayat Obstetri Sekarang
1.

Kehamilan
Komplikasi

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

Fe, jika ya berapa banyak yang diminum:.............................
TT, jika Ya jumlah/ terakhir diberikan: .........kali/ ......................
2.

Persalinan

Jenis

Tindakan

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

:

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2

Vit.
A

Menyusu

No. Registrasi:

Penolong

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Tempat

:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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