Format Dokumentasi Pengkajian Masa Nifas

2-6 Jam Postpartum

No. Registrasi : .......................................................................................

No. RM :........................................................................................

Nama Pengkaji : .......................................................................................

Hari/ Tanggal : ........................................................................................

Waktu Pengkajian: ........................................................................................

Tempat Pengkajian: ......................................................................................

Subjektif

I. Identitas Diri

Klien Suami
Nama
Umur
Alamat
No. Telepon
Agama
Pendidikan
Pekerjaan
Golongan darah
Suku
Nama bayi

II. Yang dirasakan klien :

....................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

III. Riwayat Obstetri Lalu

Tahu Anak Kehamilan Persalinan Bayi Nifas
n ke Lam FE TT Penolon Tempat Jeni H/M JK BB/TB Vit.A Menyusui
 a g s

IV. Pengkajian Nifas Saat ini

Perdarahan
- Warnanya : ..................................................................
- Lokia :..........................................................................
- Banyaknya :.................................................................
Menyusui dan laktasi : .......................................................
Eliminasi : ..........................................................................

V. Riwayat Kesehatan
Alergi: .......................................................................................
HIV/AIDS dan sifilis: .................................................................
Riwayat operasi:.......................................................................
Konsumsi obat-obatan atau jamu-jamuan: ...............................
Imunisasi TT
- Sudah/belum: ..............................................................
- Terakhir imunisasi TT: .................................................

VI. Riwayat Kesehatan Keluarga (untuk kunjungan pertama)

Kalau bukan persalinan pertama, apakah pasca persalinan
sebelumnya mengalami postpartum depression/psychosis? ....
.................................................................................................

Objektif
A. Keadaan Umum
Kesadaran: ....................................................................................
Ekspresi wajah: .............................................................................
Kebersihan: ...................................................................................

B. Tanda-tanda vital
Tekanan darah: ....................................................................... mmHg
Temperatur:................................................................................. oC
Nadi: ...................................................................................... x/menit
 C. Pemeriksaan Fisik
Dada

a. Payudara
- Bentuk:.................................................................................
- Puting susu: .........................................................................
- Kolostrum:............................................................................
b. Abdomen
- Uterus/involusi
Tinggi Fundus Uteri: ..................................................................
kontraksi :..................................................................................
c. Kandung kemih: ..............................................................................
d. Genitalia
- Perdarahan vagina: ..............................................................

2-6 Hari Postpartum

No. Registrasi : ........................................................................................

Nama Pengkaji : .......................................................................................

Hari/ Tanggal : ........................................................................................

Waktu Pengkajian: ........................................................................................

Tempat Pengkajian: ......................................................................................

A. Riwayat Nifas Saat ini

Yang dirasakan klien: ...............................................................
Perdarahan
- Warna:...............................................................................
- Lokia: ................................................................................
- Banyaknya: .......................................................................
Tanda-tanda bahaya: ...............................................................
- Demam:.............................................................................
- mual muntah:.....................................................................
- pusing yang hebat: ............................................................
- nyeri tungkai: .....................................................................
 - sakit kepala: ......................................................................
Masalah pada pencernaan dan perkemihan (inkontinensia, rasa
panas selama berkemih, susah berkemih, konstipasi, dan mudah
sekali berkemih): ......................................................................
Perasaan ibu tentang bayinya dan kemampuannya untuk
merawatnya:.............................................................................
.................................................................................................
Perasaan pasangan dan keluarga ibu mengenai bayinya?.......
.................................................................................................
.................................................................................................
Menyusui: .................................................................................
.................................................................................................

B. Keadaan Pikososial
- Pengambil keputusan keluarga: ...................................................
- Adat istiadat yang berkaitan dengan nifas dalam kebudayaan ibu
(jika ada): .....................................................................................
- Penggunaan KB: ..........................................................................
.....................................................................................................
- Status pernikahan klien: ...............................................................

C. Aktifitas Sehari-hari
a. Pola makan
Menu: .............................................................................
.......................................................................................
Frekuensi: .......................................................................
Porsi: ..............................................................................
Pantangan: .....................................................................
b. Pola minum
Frekuensi per hari: ..........................................................
Jenis minuman:...............................................................
Ukuran: ...........................................................................
Pantangan: .....................................................................
c. Pola istirahat
Lamanya: ........................................................................
 Istirahat siang: ................................................................
d. Personal hygiene :......................................................................
e. Eliminasi
BAB (pertama BAB pasca persalinan): ................................
BAK
- Frekuensi: .....................................................................
- Volume urine:................................................................
f. Gaya Hidup
Merokok: ..............................................................................
Konsumsi alkohol atau obat-obatan terlarang: .....................

Objektif
A. Keadaan Umum
Kesadaran: ....................................................................................
Ekspresi wajah : ............................................................................
Kebersihan: ...................................................................................
Cara berjalan: ...............................................................................

B. Tanda-tanda vital
Tekanan darah: ................................................................... mmHg
Temperatur:............................................................................ oC
Nadi: .................................................................................. x/menit

C. Pemeriksaan Fisik
Kepala dan Leher
a. Konjungtiva
Normal Anemis

Dada
 a. Payudara
- Puting susu: ...................................................................
- ASI yang keluar: encer / tidak
- Pembengkakan ASI: ya / tidak
b. Abdomen ....................................................................................
- Uterus/involusi (TFU) : ........................................................
- Kontraksi: ............................................................................
- Kandung kemih : ..................................................................

c. Genitalia
- Perdarahan vagina: ............................................................
- Lokia: ..................................................................................
o Jumlah: ....................................................................
o Warna: .....................................................................
o Bau: .........................................................................
- Lesi: ....................................................................................
- Hemoroid: ya / tidak
- Penjahitan laserasi: ............................................................
Kebersihan: ................................................................
Tanda Infeks:: basah kering

nanah tidak ada

nanah

d. Ekstrimitas atas
- Bentuk: oedema / tidak
- Warna ujung kuku: ...............................................................
e. Ekstrimitas bawah
- Bentuk: oedema/tidak
- Warna ujung kuku: ...............................................................
- Refleks Patella: ...................................................................
- Tanda Homan: .....................................................................

D. Pemeriksaan Laboratorium
HB : ..................................................................................................
2 Minggu Postpartum
No. Registrasi : .......................................................................................

Hari/Tanggal : .......................................................................................

Nama Pengkaji : .......................................................................................

Waktu Pengkajian : .......................................................................................

Nama Klien : .......................................................................................

Subjektif

1. Apa yang klien rasakan : ................................................................

..........................................................................................................
..........................................................................................................
2. KB
Rencana memiliki anak lagi : .............................................................
Metode KB sebelumnya
- berapa lama: ...............................................................................
- efek samping: ..............................................................................
- jenis: ............................................................................................
- terakhir menggunakan: ................................................................
- alasan berhenti):..........................................................................
Metode KB yang akan digunakan: .....................................................

3. Riwayat nifas saat ini

Proses menyusui : .............................................................................
Perdarahan per vaginam (banyaknya, warnanya, baunya): ...............
Lokhia : .............................................................................................
Asuhan selain dari bidan sejak kunjungan terakir: .............................
Tanda bahaya: ..................................................................................
- Demam
- Mual muntah
- Sakit kepala
- Nyeri tungkai
- Payudara bengkak, bernanah
- Nyeri epigastrium
- Penglihatan kabur
- Edema wajah/ ekstremitas/
- Sakit punggung bagian bawah
4. Psikososial
Perasaan klien, pasangan, dan keluarga terhadap bayinya : .............
..........................................................................................................
..........................................................................................................
..........................................................................................................

5. Aktivitas sehari-hari
Eliminasi
- BAK (frekuensi, masalah): ...........................................................
- BAB (frekuensi, masalah): ...........................................................
Nutrisi
- Menu: ..........................................................................................
- Frekuensi: ...................................................................................
- Porsi: ...........................................................................................
- Pantangan: ..................................................................................
Hidrasi
- Frekuensi/hari:.............................................................................
- Jenis minuman: ...........................................................................
- Banyaknya: .................................................................................
- Pantangan: ..................................................................................
Pola istirahat (lama tidur): .................................................................
Personal hygene
- Frekuensi/hari:.............................................................................
- Cara membersihkan kemaluan: ...................................................

Rencana berhubungan seksual: ........................................................

..........................................................................................................
6 Minggu Postpartum

No. Registrasi : ............................................................................................

No. RM : ............................................................................................

Nama Pengkaji: ............................................................................................

Nama Klien : .............................................................................................

Hari/Tanggal : .............................................................................................

Waktu Pengkajian: ........................................................................................

Tempat : .............................................................................................

Subjektif :

1. Aktivitas sehari-hari
a. Kebutuhan nutrisi
Menu:...............................................................................
Frekuensi: ........................................................................
Porsi: ...............................................................................
Pantangan: ......................................................................
b. Kebutuhan hidrasi
Frekuensi: ........................................................................
Jenis minuman:................................................................
Banyaknya: ......................................................................
c. Istirahat: ......................................................................................
d. Eliminasi (BAB/BAK) ...................................................................
2. Apa yang ibu rasakan:.......................................................................
..........................................................................................................
..........................................................................................................
3. Rencana KB
a. Riwayat KB yang lalu
jenis KB:.................................................................................
kapan terakhir menggunakan: ................................................
efek samping yang dirasakan:................................................
..............................................................................................
lama menggunakan KB: .........................................................
 alasan berhenti: .....................................................................
..............................................................................................
b. Rencana metode KB yang akan digunakan: ................................
c. Kapan metode tersebut akan dimulai: .........................................