POLTEKKES KEMENKES YOGYAKARTA

Nama .....................................
JURUSAN KEBIDANAN
Keterampilan ke.....................
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
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ASUHAN KEBIDANAN PADA IBU NIFAS

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No Register
Masuk RS Tgl, Jam
Dirawat di Ruang
Biodata
Nama
:
Umur
:
Agama
:
Suku/ Bangsa
:
Pendidikan
:
Pekerjaan
:
Alamat
:
No.Telp/Hp
:

:
:
:
Ibu
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Suami
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DATA SUBYEKTIF (Tanggal.. Jam..WIB)

1. Keluhan Utama
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2. Riwayat Perkawinan
Kawin .............kali, kawin pertama umur............tahun, dengan suami sekarang...............tahun
3. Riwayat Menstruasi
Menarche umur......... tahun, siklus............hari, teratur/ tidak. Lamanya.........hari, sifat darah encer/ beku.
Bau .............., fluor albus ya/ tidak. Disminorea ya/ tidak. Banyaknya........................................................
HPM.............................................................
HPL...........................................................................
4. Penyakit sistemik yang pernah/sedang diderita
......................................................................................................................................................................... ....
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5. Penyakit yang pernah/sedang diderita keluarga
......................................................................................................................................................................... ....
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6. Riwayat Kehamilan, Persalinan, dan nifas yang lalu
P................ Ab...................Ah........................
Persalinan
Nifas
Hamil
Komplikasi
Tgl
Jenis
BB
Laktasi
keUK
Oleh
JK
Komplikasi
lahir
persalinan
lahir
Ya/tdk
Ibu
Bayi

7. Riwayat Kontrasepsi yang digunakan

Mulai memakai
Jenis
No
Alkon
Tgl Oleh
Tempat Keluhan Tgl

8. Riwayat kehamilan dan persalinan terakhir

Berhenti/ ganti
Keterangan
Oleh
Tempat Keluhan

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
==========================================================
========================================

Masa Kehamilan : ....................minggu

Tempat Persalinan : ..................................................................... Penolong ...............................................
Jenis Persalinan : spontan/ tindakan ........................................................................................................
Atas indikasi.................................................................................................................
Komplikasi
: ......................................................................................................................................
Plasenta
: lengkap/ tidak
a. Lahir
: spontan / manual
b. Kelainan
: ....................................................................................................,.................................
Perineum
: utuh/ ruptur (derajat 1 / 2 / 3 / totalis)
Episiotomi (medialis/lateralis/mediolateralis)
Tidak dijahit/ dijahit/ tanpa anesthesia
Perdarahan
: Kala I..............cc. Kala II...............cc. Kala III.............cc. Kala IV.............cc
Tindakan lain
: infus ............................................................................................................................
Transfusi darah ............................................................................................................
Lama persalinan : Kala I .............jam ...........menit, kala II ............jam ..............menit
Kala III ..........jam ...........menit, kala IV ...........jam .............menit
Operasi ..........jam ...........menit
9. Keadaan bayi baru lahir
Lahir tanggal
: ...........................................................jam.......................WIB
Masa gestasi
: .............................minggu
BB/PB lahir
: ...................gram/ ..............cm
Nilai APGAR
: 1menit/ 5menit/ 10menit/ 2jam : ........./........./........./...........
Cacat bawaan
: ................................................................................................................................
Rawat Gabung
: ................................................................................................................................
10. Riwayat post partum
Ambulasi
: ............................................................................................................................................
Pola makan
: ............................................................................................................................................
Pola eliminasi
a. BAB
: ............................................................................................................................................
b. BAK
: ............................................................................................................................................
11. Keadaan psikososialspiritual
a. Kelahiran ini
Diinginkan
Tidak diinginkan
b. Penerimaan ibu terhadap kelahiran bayinya
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c. Pengetahuan ibu tentang masa nifas dan perawatan bayi
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d. Tanggapan keluarga terhadap persalinan
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e. Keadaan sosial ekonomi keluarga
1) Pekerjaan pokok
:
2) Pekerjaan sampingan
:
3) Pendapatan
:
f. Keadaan rumah dan lingkungan
1) Rumah
a) Status kepemilikan
:
b) Dinding rumah
:
c) Langit-langit
:
d) Atap rumah
:
e) Lantai
:
f) Ventilasi
:
g) Penerangan
:
h) Ukuran rumah
:
i) Pembagian rumah
:
2) Sarana masak
a) Bahan bakar
:

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
==========================================================
========================================

3)

4)

5)

6)

7)
8)

b) Tempat penyimpananan alat dapur

c) Ventilasi dapur
d) Kebersihan dapur
Sampah
a) Sarana pembuangan
b) Tempat pembuangan
c) Letak pembuangan
d) Pengelolaan sampah
e) Jarak tempat pembuangan
Sumber air
a) Sumber air minum
b) Jarak sumber air minum dengan WC
c) Pencemaran air
d) Kualitas air
Jamban keluarga
a) Status kepemilikan jamban
b) Jenis
c) Letak
d) Kebersihan
Saluran pembuangan air limbah
a) Jenis limbah
b) Bak limbah
c) Saluran limbah
d) Kebersihan
e) Jarak limbah dengan sumber air
Kandang
Pemanfaatan pekarangan

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DATA OBYEKTIF (Tanggal.. Jam..WIB)

1. Pemeriksaan Fisik
a. Keadaan umum
:....................................................kesadaran......................................................
b. Status Emosional
: ..........................................................................................................................
c. Tanda vital
Tekanan Darah
: ............................mmHg
Nadi
: ............................ x/menit
Pernafasan
: ............................ x/menit
Suhu
: ............................C
d. BB/ TB
: ...........................kg /..............cm
e. Kepala Leher
Edema wajah
: ..........................................................................................................................
Mata
: ..........................................................................................................................
Mulut
: ..........................................................................................................................
Leher
: ..........................................................................................................................
f. Payudara
: ..........................................................................................................................
g. Abdomen
: ..........................................................................................................................
h. Ekstremitas
: ..........................................................................................................................
i. Vulva
: ..........................................................................................................................
j. Anus
: Hemoroid / tidak

2. Pemeriksaan penunjang
.............................................................................................................................................................................
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ANALISA (Tanggal.. Jam..WIB)

POLTEKKES KEMENKES YOGYAKARTA

JURUSAN KEBIDANAN
JL. Mangkuyudan MJ III/304 Yogyakarta. Telp (0274) 374331
==========================================================
========================================

PENATALAKSANAAN (Tanggal.. Jam..WIB)