KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

ASUHAN KEBIDANAN POSTPARTUM PATOLOGIS

DENGAN ……………………………
DI..............................

Tanggal / waktu pengumpulan data :

Nomor register pasien :
Tempat pengumpulan data :

I. PENGUMPULAN DATA DASAR

A. DATA SUBYEKTIF (S)
1. Identitas
Nama Ibu : ......................... Nama Suami : .........................
Umur : ....... Tahun Umur : ....... Tahun
Pendidikan : ......................... Pendidikan : .........................
Agama : ......................... Agama : .........................
Pekerjaan : ......................... Pekerjaan : .........................
Alamat : .....................................................................................
.....................................................................................
2. Alasan Kunjungan
.................................................................................................
.................................................................................................
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3. Keluhan Utama Saat Ini
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 4. Riwayat Perjalanan Penyakit
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Tanda Bahaya Masa Nifas
..............................................................................................................
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..............................................................................................................
..............................................................................................................
5. Riwayat Persalinan Sekarang
a. Tanggal/jam persalinan : ..............................................................
b. Penolong persalinan : ..............................................................
c. Tempat persalinan : ..............................................................
d. Jenis persalinan (spontan, vakun, SC) : ......................................
e. Keadaan bayi ( BB/PB bayi,Jenis kelamin, hidup/mati) :
......................................................................................................
f. Komplikasi selama kehamilan dan persalinan : ..........................
g. Robekan jalan lahir/episiotomi : .................................................

6. Riwayat Persalinan Dan Nifas Yang Lalu

Hamil Usia Tempat Jenis BBL Komplikasi/masalah
Penolong JK Usia Ket
Ke- khmln persl. persl. (kg) Hamil Persl. Nifas

7. Riwayat Psikososial
a. Konsumsi zat besi : .............................................................
b. Konsumsi Obat-obatan : .............................................................
c. Kebutuhan Nutrisi/diet
1) Frekuensi : ........................................................................
2) Komposisi : ........................................................................

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 3) Porsi : ........................................................................
4) Pantangan : ........................................................................
5) Masalah : ........................................................................
d. Pemberian ASI
1) Frekuensi : ........................................................................
2) Lamanya : ........................................................................
3) Kesulitan : ........................................................................
e. Pola Eliminasi (BAK & BAB)
1) Frekuensi : ........................................................................
2) Konsistensi : ........................................................................
3) Warna : ........................................................................
4) Kesulitan : ........................................................................
f. Istirahat
1) Lama : ........................................................................
2) Kesulitan : ........................................................................
g. Ketidaknyamanan Nyeri
1) Lokasi : ........................................................................
2) Intesitas : ........................................................................
3) Cara mengatasi nyeri : ........................................................
h. Mobilisasi
1) Duduk : ......................................................................
2) Berdiri : ......................................................................
3) Berjalan : ......................................................................
i. Personal Hygiene
1) Mandi : ...................................................................
2) Gosok gigi : ...................................................................
3) Ganti pakaian : ...................................................................
4) Potong kuku : ...................................................................
j. Hubungan seksual
1) Kenyamanan fisik : ..........................................................
2) Kenyamanan emosi : ..........................................................
k. Psikologi
1) Respon Ibu terhadap diri sendiri : ......................................
.............................................................................................
2) Respon Ibu terhadap bayi: .................................................

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 ............................................................................................
3) Respon Kelurga terhadap Ibu dan Bayi : ...........................
............................................................................................
l. Riwayat Sosial Ekonomi
1) Status perkawinan : ................................................
2) Lama perkawinan : ................................................
3) Jumlah anggota kelurga dalam satu rumah: ......................
4) Riwayat dan rencana KB : ................................................

B. DATA OBYEKTIF (O)

1. Pemeriksaan umum
a. Keadaan umum : .............................................................
b. Kesadaran : .............................................................
c. Emosi : .............................................................
2. Tanda vital
a. Nadi : .......... x/menit
b. Suhu ̊
: ......... C
c. Tekanan darah : .......... mmHg
d. Respirasi : .......... x/menit
3. Pemeriksaan fisik
a. Kepala : warna rambut hitam, distribusi merata, bersih, lesi /
massa ( )
b. Muka : simetris, pucat ( ),oedema ( )
c. Mata : konjungtiva anemis ( ), sclera ikterik ( )
d. Hidung : polip hidung ( ), pengeluaran abnormal ( )
e. Telinga : pengeluaran abnormal ( ), cerumen ( )
f. Mulut : bibir.........................., stomatitis ( ), caries dentis ( )
g. Leher : bendungan vena jugularis ( ), pembesaran kelenjar
tiroid ( ), pembesaran kelenjar limfe ( )
h. Dada : simetris, pengeluaran ASI......................, putting susu
menonjol ( ), retraksi /dimpling ( ), massa ( )
i. Ketiak : pembesaran kelenjar limfe ( )
j. Abdomen :
1) luka bekas operasi : .................................................
2) kandung kemih : .................................................

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 3) Kontraksi : .................................................
4) TFU : .................................................
5) Massa/konsistensi/otot parut : ................................................
k. Genitalia :
1) Keadaan labia mayor dan minor (luka, cairan) : ......................
2) Perineum (luka laserasi, jahitan perinium) : ......................
3) Lokhea (warna, konsistensi, bau) : .......................
l. Ekstremitas atas : simetris, oedema ( ), pucat pada kuku ( )
m. Ekstremitas bawah : simetris, varises ( ), oedema ( ), pucat pada
kuku ( ), reflex patella ( )
Anus : hemoroid ( )
3. Pemeriksaan penunjang
a. Urine tgl..............
1) PP test : ...................
2) Protein Urin : ...................
3) Glukosa urine : ...................
b. Darah tgl..............
1) Hb : ................. gr%
2) Al : .................
3) HMT : .................
4) Golongan Darah : ..............

II. INTERPRETASI DATA DASAR

A. Diagnosa :
Data Dasar
 DS :..........................................................................................
..........................................................................................
..........................................................................................
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..........................................................................................
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  DO : .........................................................................................
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B. Masalah : .........................................................................................
C. Kebutuhan : .........................................................................................

III. MENGIDENTIFIKASI DIAGNOSA / MASALAH POTENSIAL

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IV. KEBUTUHAN TERHADAP TINDAKAN SEGERA
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V. RENCANA ASUHAN YANG MENYELURUH Tgl/Jam
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VI. PELAKSANAAN ASUHAN Tgl/Jam
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VII. EVALUASI ASUHAN Tgl/Jam
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Mengetahui,
Mahasiswa Pelaksana

( )

Pembimbing Lahan Pembimbing Pendidikan

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