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KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG


JURUSAN KEBIDANAN
PROGRAM STUDI D-III KEBIDANAN KEDIRI
TAHUN 2014/2015
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website :http://www.poltekkes-malang.ac.id

Format Asuhan Kebidanan Pada Ibu Nifas (PNC)

I. Pengkajian

Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :

Cara masuk :

Datang Sendiri Rujukan dari :

Diagnose :

A. DATA SUBYEKTIF
1. Keluhan
utama : ....................................................................................................................................
.................................................................................................................................................
...........
2. Riwayat menstruasi
 Usia manarche :
 Jumlah darah haid :
 HPHT :
 Keluhan saat haid :
 Lama haid :
 Flour albus :
 TP :
 Keluhan haid :

Disminorhoe Spoting Menorrhagia Premenstrual syndrome

Dll..............

3. Riwayat kehamilan,persalinan, dan nifas yang lalu.


G............................P.............................A.........................Hidup..............................

Tahun Tempat Usia Jenis Penyulit Anak


No. Penolong KB Lama
Persalinan Persalinan Kehamilan Persalinan Persalinan JK BB PB
4. Riwayat kesehatan penyakit yang pernah diderita :
 Anemia
 Hipertensi
 Kardiovaskular
 TBC
 Diabetes
 Malaria
 IMS (Sphilis, GO, HIV/AIDS, dll)
 Lain-lain....
Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................
Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
Lain-lain
5. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
...............................................................................................................................................
6. Status perkawinan : ya/tidak
Kawin.............kali, kawin usia..............tahun, lama menikah....................tahun
7. Riwayat psiko sosial ekonomi
- Respon ibu dan keluarga terhadap kehamilan
................................................................................................................................................
- Penggunaan alat kontrasepsi KB
................................................................................................................................................
- Dukungan keluarga
................................................................................................................................................
- Pengambilan keputusan dalam keluarga
................................................................................................................................................
- Gizi yang dikonsumsi dan kebiasaan makan
................................................................................................................................................
- Kebiasaan hidup sehat
................................................................................................................................................
- Beban kerja sehari
................................................................................................................................................
- Tempat dan penolong persalinan yang diinginkan
................................................................................................................................................
- Penghasilan keluarga
................................................................................................................................................

8. Riwayat KB dan rencana KB


Metode yang pernah dipakai : ......................................., Lama : ...................bulan/tahun
Komplikasi dari KB : ..................................., Rencana KB
selanjutnya: ..................................................................................................

9. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS Endometritis
Polip serviks Kanker kandungan Operasi kandungan Perkosaan
DUB dll........................

10. Pola makan / minum/ eliminasi/ istirahat


- Pola minum : .................gelas/hari alkohol Jamu Kopi

- Pola eliminasi :
BAK.................cc/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK terakhir
jam :.........
BAB..................kali/hari, karakteristik: lembek/keras, BAB terakhir jam :.........................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................
- Dukungan keluarga : Suami Orang tua Mertua Keluarga lain

B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla : adanya pembesaran kelenjar limfe/tidak
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang melebur
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
b. TFU : .............................., Kontraksi Uterus : Baik/lembek
Diastesis rectus abdomonis : +/-, ............................
Kandung kemih : Kosong/ penuh
Vulva Vagina : Lochea.................., Bau +/-
Luka Jalan lahir : Ruptur/Episiotomi, bengkak/tidak, bersih/kotor, luka
jahitan bertaut/tidak, basah/kering
Tanda-tanda Reeda (Red, Echimosis, Edema, Discharge, Aproximal)
Ekstremitas : Tromboflebitis (ada/tidak, berapa lama....................)

4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- USG : ...........................................

C. ANALISA
................................................................................................................................................
................................................................................................................................................
D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................

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Kediri,............................

Pembimbing Praktik Mahasiswa

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

NIP. NIM.

Dosen Pembimbing

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

NIP.