ASUHAN KEPERAWATAN IBU NIFAS

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Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :

A. DATA SUBYEKTIF
1. IDENTITAS
Nama : .......................................... Nama Suami :

Umur : .......................................... Umur :

Agama : .......................................... Agama :

Pendidikan : .......................................... Pendidikan :

Pekerjaan : .......................................... Pekerjaan :

Penghasilan : .......................................... Penghasilan :

Alamat : .......................................... Alamat :

No Reg : ..........................................

Diagnosa Medis : ..........................................

2. KELUHAN
a. Saat MRS
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b. Saat Pengkajian (Keluhan Utama)

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3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
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3.2 Penyakit sekarang
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3.3 Penyakit Keluarga
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4. RIWAYAT OBSTETRI / KEBIDANAN

4.1 Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .....................................................................
Menarche :.......................................................... Dismenorhea: .....................................................................
Lama :.......................................................... Flour Albus : .....................................................................
Banyak : ........................................................
Siklus :.........................................................

5. RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU

No Tgl/Bln/Thn Usia Tempat Jenis Penolong Penyulit Anak Nifas Usia Hidup/
JK BB PB
(Gravida) Persalinan Kehamilan Persalinan Persalinan anak Mati

6. RIWAYAT KEHAMILAN SEKARANG

6.1 Riwayat Kehamilan ini : G.....P......................Ab........................

6.2 HPHT :................................ TP :....................................

 6.3 Usia Kehamilan:......................

6.4 Keluhan hamil muda ..............................................................................................................................

6.5 Kapan terasa gerakan awal................................................................................................................................

6.6 ANC.....................x, di........................................................................................................................................

6.7 Status TT............................................................................................................................................................

6.8 Terapi yang pernah diberikan..............................................................................................................................

6.9 Penyuluhan yg pernah didapat

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7. RIWAYAT PERSALINAN DAN NIFAS SEKARANG

 Tempat Persalinan:...............................

 Penolong:...............................................

 Jenis Persalinan spontan/tindakan..................................................................................................

atas indikasi....................................................................................................................................

 Komplikasi:......................................................................................................................................

Plasenta ..........................................................................................................................................

tali pusat........................cm

Perenium : ...........................................................................................................................

Epidemiologi .........................................................................................................................

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 II : ..........................jam ....................menit

 Kala IV : ........................jam......................menit

 Keadaan Bayi Baru Lahir

Lahir Tanggal : ........................jam...........................

Masa Gestasi : ......................minggu

BB/ PB lahir : .........................gram / ..................cm

Apgar :………………………………………

Cacat bawaan : .....................................

Rawat gabung : ....................................

8. RIWAYAT KB

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9. RIWAYAT PERNIKAHAN

Usia....................berapa kali.................................

Jarak perkawinan & kehamilan pertama................................................th

10. RIWAYAT PSIKOSOSIAL SPIRITUAL & KELUARGA

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11. POLA AKTIFITAS

Kebutuhan Dasar Sebelum Hamil Saat Hamil

1. Cairan & Makanan

2. Eliminasi

3. Istirahat & Tidur

4. Personal hygiene

5. Aktivitas

6. Pola Sexualitas

B. DATA OBJEKTIF

1. KEADAAN UMUM :

- Kesadaran:.........................................................................................................................................

- TTV :............................................................................................................................................

- TB :...........................................................................................................................................

- BB (sebelum & saat hamil :...................................................................................................................

2. PEMERIKSAAN FISIK

a. Pemeriksaan Kepala ( Inspeksi, Palpasi)

- Rambut :.............................................................................................................................................

- Wajah :..............................................................................................................................................

- Mata :..............................................................................................................................................

- Hidung :..............................................................................................................................................

- Mulut :.............................................................................................................................................

- Telinga :..............................................................................................................................................

b. Pemeriksaan Leher :...................................................................................................................................

c. Pemeriksaan Thorax (Inspeksi, Palpasi, Auskultasi)

- Payudara

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- Jantung

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- Paru

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d. Pemeriksaan Abdomen (Inspeksi, Palpasi, Auskultasi)

Inspeksi : ......................................................................................................................................................

Palpasi : .......................................................................................................................................................

Auskultasi : .................................................................................................................................. .....................

e. Pemeriksaan Ekstremitas

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f. Pemeriksaan Genetalia

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g. Pemeriksaan Integumen

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3 PEMERIKSAAN PENUNJANG

a. Laboratorium/USG

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b. Radiologi

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4. TERAPI

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ANALISA DATA

Nama: No. RM:

Diagnosa Medis :
Data penunjang Penyebab Masalah
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Data penunjang Penyebab Masalah

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DIAGNOSA KEPERAWATAN

Nama : No. RM:

Dx Medis :

No Tgl. Diagnosa Keperawatan

Muncul
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 RENCANA TINDAKAN KEPERAWATAN

Nama : ……………………………… No.RM : …………………………………..

Diagnosa Medis : ………………………………
Tgl Diagnosa Keperawatan NOC NIC
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Tgl Diagnosa Keperawatan NOC NIC

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 IMPLEMENTASI

Nama Klien : Tanggal Pengkajian :

Diagnosa Medis :

Tanggal No. Dx Jam Implementasi Evaluasi TTD & Nama

Keperawatan Terang

Tanggal No. Dx Jam Implementasi Evaluasi TTD & Nama

Keperawatan Terang