FORMAT ASUHAN KEBIDANAN NIFAS NORMAL

Makalah Disusun Guna Memenuhi Tugas Dokumentasi Kebidanan

Dosen Pengampu : Winarni, S. SiT.

Disusun Oleh :

ANGKATAN TAHUN 2015

PRODI D-III KEBIDANAN

STIKES ‘AISYIYAH SURAKARTA
2015
ASUHAN KEBIDANAN PADA IBU NIFAS ... POST PARTUM....
PADA NY. ... USIA ... TAHUN ... P ... A...
DI ...

Tanggal masuk : .............................

Jam : .............................
Ruang : .............................
No.Register : .............................

I. DATA PENGKAJIAN
Tanggal : .................................
Jam : .................................
Oleh : .................................

A Data Subjektif
1 Identitas
Nama Pasien : .........................................................
Umur : .........................................................
Suku : .........................................................
Agama : .........................................................
Pendidikan : .........................................................
Penghasilan : .........................................................
Pekerjaan : .........................................................
Alamat : .........................................................

Nama Suami : .........................................................

Umur : .........................................................
Suku : .........................................................
Agama :.........................................................
Pendidikan : .........................................................
Penghasilan :.........................................................
Pekerjaan : .........................................................
Alamat : .........................................................

2 Alasan Masuk/Keluhan Utama :

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

3 Riwayat Menstruasi
Menstruasi : .........................................................
Sifatdarah : .........................................................
Siklus : .........................................................
Lama : .........................................................
Warna :.........................................................
Bau : .........................................................
Keluhan saat menstruasi : .........................................................
Fluor albus : .........................................................
HPHT : .........................................................

4 Riwayat Pernikahan
Status Pernikahan :.........................................................
Lama Pernikahan :.........................................................
Usia Saat Menikah :.........................................................

5. Riwayat Kontrasepsi : .........................................................

Pernah KB :.........................................................
Jenis Kontrasepsi :.........................................................
Lama KB : .........................................................
Keluhan :.........................................................
Rencana KB Setelah Nifas :.........................................................
Rencana Beralih Ke Kontrasepsi:.....................................................

6. Riwayat Kehamilan, Persalinan, Nifas yang lalu

PERSALINAN NIFAS
Komplikasi
Penolong

N
Perdarahan
Anak

Umur
Jenis
BB Lahir

Komplikasi
TGL LAHIR

o Kehami
JK

Laktasi

persali
lan
nan
Ibu Bayi
1.
2.
3.

a. Riwayat Kehamilan
 TM I : .........................................................

TM II : .........................................................

TM III : .........................................................

b. Riwayat Persalinan

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
c. Riwayat Nifas
.............................................................................................................................
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7. Riwayat Kehamilan, Persalinan, Nifas sekarang
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
a. Riwayat Kehamilan
TM I : .........................................................
TM II : .........................................................
TM III : .........................................................

b. Riwayat Persalinan
Kala I : .........................................................
Kala II : .........................................................
Kala III : .........................................................
Kala IV : .........................................................
c. Riwayat Nifas
Riwayat perdarahan, kejadian dan waktu berkala :
Kala I : ... cc ... jam ...menit
Kala II : ... cc ...jam ... menit
Kala III : ... cc ... jam ... menit
Kala IV : ... cc ... jam ... menit
Jumlah : ...
Lama persalinan :....... jam
7. Riwayat Kesehatan
1) Riwayat Kesehatan Lalu :
 ..................................................................................................................
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2) Riwayat Kesehatan Sekarang :

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

3) Riwayat Kesehatan Keluarga :

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

8. Kehidupan Sosial Budaya

Hubungan dengan keluarga :.........................................................
Hubungan dengan orang lain :.........................................................
Kegiatan sosial :.........................................................
Lingkungan :.........................................................
Adat-istiadat :.........................................................

9. Riwayat Psikososial
Respon keluarga terhadap ibu dan bayi :.............................................
Respon ibu terhadap bayi :.............................................
Respon ibu terhadap diri sendiri :.............................................

10. Data Pengetahuan

1) Masa Nifas
Pemberian ASI :.............................................
Perawatan Payudara :.............................................
Perawatan Bayi Baru Lahir :.............................................
Nutrisi Pada Masa Nifas :.............................................
Senam Nifas :.............................................
Tanda Bahaya Nifas :.............................................
Keluarga Berencana :.............................................

2) Menyusui/Makanan Bayi
Manfaat ASI :.............................................
Makanan Bayi :.............................................

11. Pola Pemenuhan Kebetuhan Sehari-hari

a. Nutrisi
 1) Pola Makan
Kebiasaan :.............................................
Setelah bersalin :.............................................
Keluhan :.............................................

2) Pola Minum
Kebiasaan :.............................................
Setelah melahirkan :.............................................
Keluhan :.............................................

b. Eliminasi
Kebiasaan : BAB :.............................................
BAK :.............................................
Setelah melahirkan : BAB :.............................................
BAK :.............................................
Keluhan :.............................................

c. Istirahat
Kebiasaan :.............................................
Setelah melahirkan :.............................................
Keluhan :.............................................

d. Personal Hygiene
Kebiasaan :.............................................
.............................................
Setelah melahirkan :.............................................
.............................................
Keluhan :.............................................
.............................................

e. Aktivitas
..........................................................................................
..........................................................................................

B. DATA OBYEKTIF
1. Keadaanumum :.............................................
2. Kesadaran :.............................................
3. Vital sign :
TD :.............................................
S :.............................................
N :.............................................
RR :.............................................
4. PemeriksaanFisik
a. Kepala
Bentukkepala : .............................................
Rambut : .............................................
Muka :.............................................
Mata : .............................................
Hidung :.............................................
Mulut :.............................................
Telinga : .............................................
b. Leher :.............................................
c. Dada :.............................................
d. Mamae :
Pembesaran mamae :.............................................
Puting susu :.............................................
Colostrum :.............................................
e. Ketiak :.............................................
f. Abdomen
Inspeksi abdomen :.............................................
TFU :.............................................
Kontraksi uterus :.............................................
Diastasisrekti :.............................................
g. Ekstremitas
Atas :.............................................
Bawah : .............................................
h. Genetalia :
Vulva :
Oedema : .............................................
Varices : .............................................
Pengeluaran pervaginam : .............................................
Kelenjar bartolini : .............................................
Kelenjar skene : .............................................
Luka : .............................................
Anus :.............................................
 5. PemeriksaanPenunjang
a. Laboratorium :.............................................
b. Radiologi :.............................................

II. INTERPRETASI DATA

Tanggal :.............................................
Jam : .............................................
DiagnosaKebidanan
............................................................................................................................
............................................................................................................................
Data Dasar
S : .....................................................................................................................
....................................................................................................................
O : Keadaanumum : .............................................
Kesadaran :.............................................
Vital Sign : TD :............. R :.............
N :............. S :.............
Payudara : .............................................
Abdomen : .............................................
Genetalia : .............................................

III.DIAGNOSA POTENSIAL
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IV. ANTISIPASI MASALAH SEGERA

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V. PERENCANAAN
Tanggal :.........................................................
 Jam :.........................................................
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VI. PELAKSANAAN
Tanggal :.........................................................
Jam :.........................................................
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VII. EVALUASI
Tanggal :.........................................................
Jam :.........................................................

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