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 ...

Tanggal Pengkajian : ..........................................................

Jam : ..........................................................
Tempat pengkajian : ..........................................................

A. DATA SUBJEKTIF
1. Identitas
Nama Ibu : ......................... Nama Suami :.........................
Umur : ....... Tahun Umur : ....... Tahun
Pendidikan : ......................... Pendidikan : .........................
Agama : ......................... Agama : …………………
Suku/bangsa : ………………… Suku/bangsa : .........................
Pekerjaan : ......................... Pekerjaan : .........................
Alamat : .....................................................................................
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2. Alasan Kunjungan
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3. Keluhan utama
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4. Riwayat Perjalanan Penyakit
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Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017
Nama / NIM : / P07124116
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5. Tanda Bahaya Nifas
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6. Riwayat kesehatan
a. Riwayat kesehatan dahulu
1) Jantung : ..........................................................
2) Asma : ..........................................................
3) TBC : ..........................................................
4) Ginjal : ..........................................................
5) DM : ..........................................................
6) Malaria : ..........................................................
7) HIV / AIDS : ..........................................................

b. Riwayat kesehatan sekarang

1) Jantung : ..........................................................
2) Hipertensi : ..........................................................
3) TBC : ..........................................................
4) Ginjal : ..........................................................
5) DM : ..........................................................
6) Malaria : ..........................................................
7) HIV / AIDS : ..........................................................

c. Riwayat kesehatan keluarga

1) Jantung : ..........................................................
2) Asma : ..........................................................
3) Hipertensi : ..........................................................
4) TBC : ..........................................................
5) Ginjal : ..........................................................
6) DM : ..........................................................
7) Malaria : ..........................................................
8) HIV / AIDS : ..........................................................
9) Kembar : ..........................................................

7. Riwayat perkawinan
Nikah......x, umur......tahun, dengan suami umur...... tahun, lama
pernikahan.................

8. Riwayat Obstetri
a. Riwayat Menstruasi
Menarche : ..........................................................
Siklus : ..........................................................

Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116
 Lama : ..........................................................
Banyaknya darah : ..........................................................
Bau : ..........................................................
Warna : ..........................................................
Konsistensi : ..........................................................
Keluhan : ..........................................................
Flour albus : ..........................................................

b. Riwayat kehamilan, persalinan dan nifas yang lalu

Hamil UK Tempat Penolon Jenis Penyulit BBL Ket
ke Persalinan g Persalina H P N BB JK Usi
n a

c. Riwayat Persalinan Sekarang

1. Tanggal/jam persalinan : ..............................................................
2. Penolong persalinan : ..............................................................
3. Tempat persalinan : ..............................................................
4. Jenis persalinan (spontan, vakun, SC) : ......................................
5. Keadaan bayi ( BB/PB bayi,Jenis kelamin, hidup/mati) :
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6. Komplikasi selama kehamilan dan persalinan : ..........................
7. Robekan jalan lahir/episiotomi : .................................................

d. Riwayat Psikososial
a. Konsumsi zat besi : .............................................................
b. Konsumsi Obat-obatan : .............................................................
c. Kebutuhan Nutrisi/diet
1) Frekuensi : ........................................................................
2) Komposisi : ........................................................................
3) Porsi : ........................................................................
4) Pantangan : ........................................................................
5) Masalah : ........................................................................
d. Pemberian ASI
1) Frekuensi : ........................................................................
2) Lamanya : ........................................................................
3) Kesulitan : ........................................................................
e. Pola Eliminasi (BAK & BAB)
BAB
1) Frekuensi : ........................................................................
Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017
Nama / NIM : / P07124116
 2) Konsistensi : ........................................................................
3) Warna : ........................................................................
4) Kesulitan : ........................................................................
BAK
1) Frekuensi : ........................................................................
2) Konsistensi : ........................................................................
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 : ...................................................................
j. Hubungan seksual
1) Kenyamanan fisik : ..........................................................
2) Kenyamanan emosi : ..........................................................
k. Psikologi
1) Respon Ibu terhadap diri sendiri : ......................................
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2) Respon Ibu terhadap bayi: .................................................
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3) Respon Kelurga terhadap Ibu dan Bayi : ...........................
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l. Riwayat Sosial Ekonomi
1) Status perkawinan : ................................................
2) Lama perkawinan : ................................................
3) Jumlah anggota kelurga dalam satu rumah: ......................
4) Riwayat dan rencana KB : ................................................

B. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan Umum : .......................................
b. Kesadaran : .......................................
c. Keadaan emosi : ………………………………
2. Tanda-Tanda Vital:
Tekanan darah : .......................mmHg
Nadi : .......................x/menit

Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116
 Respirasi : .......................x/menit
Suhu : ........................˚C

3. Pemeriksaan fisik
a. Kepala dan rambut
Kebersihan : ................
Distribusi rambut : ..................
Alopesia/lesi : ...................
Infeksi kulit : .......................
b. Wajah
Warna/pucat : .........................
Oedema : ..........................
c. Mata
Konjungtiva : ………..
Sklera : ………..
d. Mulut dan gigi
Bibir (lembab/kering/pecah-pecah) : ………..
Rahang dan lidah (pucat/lesi) : ………..
Gigi dan gusi : ………..
e. Leher
Kelenjar thyroid : ……………………..
Kelenjar getah bening/Limfe : ……………………..
Bendungan vena Jugularis : ……………………..
f. Payudara
Simetris : …………..
Areola : …………..
Putting susu : …………..
Benjolan/Tumor/massa : …………..
Rasa nyeri tekan : …………..
Pengeluaran : …………..
g. Abdomen :
luka bekas operasi : .................................................
kandung kemih : .................................................
Kontraksi : .................................................
TFU : .................................................
Massa/konsistensi/otot parut : ................................................
h. Genitalia :
Keadaan labia mayor dan minor (luka, cairan) : ......................
Perineum (luka laserasi, jahitan perinium) : ......................
Lokhea (warna, konsistensi, bau) : .......................
i. Ekstremitas
Kemerahan : ...............................................
Varices : ...............................................
Tanda homan : ...............................................

Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116
 4. Pemeriksaan penunjang
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C. ANALISA
1. Diagnosa kebidanan
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2. Masalah
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3. Kebutuhan
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D. PENATALAKSANAAN Tanggal :....................................., Pukul :..............wita

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Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116
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Mengetahui
Mahasiswa Praktek

Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116
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Asuhan Kebidanan Post Partum Patologis Poltekkes Mataram 2016/ 2017

Nama / NIM : / P07124116