Askeb Nifas

Program Studi D III Kebidanan Respati

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No. Register : ………………………….

Masuk RS tanggal / jam : ………………………….
Dirawat diruang : ………………………….

I. PENGKAJIAN Tanggal : ...................., Jam : ...............WIB, Oleh : ...........................…......

A. IDENTITAS
Ibu
Nama : ...................................................
Umur : ...................................................
Agama : ...................................................
Suku/Bangsa : ...................................................
Pendidikan : ...................................................
Pekerjaan : ...................................................
Alamat : ...................................................
No. Telp : ...................................................

B. DATA SUBYEKTIF
1. Alasan datang
......................................................................................................................................................
......................................................................................................................................................

2. Keluhan utama
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

3. Riwayat menstruasi
Menarche : ….. tahun
Lama : ….. hari Teratur : ………..……………
Sifat darah : ……………..…….. Keluhan : …………..…………

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Program Studi D III Kebidanan Respati

4. Riwayat perkawinan
Lama : …… tahun Usia menikah pertama kali :……. tahun

5. Riwayat obstetrik : P..... A..... Ah......

6. Riwayat kontrasepsi yang digunakan
No. Alat/Cara Pasang/Mulai Lepas
Tgl/Bln/Thn Oleh Tempat Tgl. Oleh Tempat Masalah

9. Pola Pemenuhan kebutuhan sehari-hari

a. Pola nutrisi
Makan
Frekuensi : .......x/hari, Porsi : ..............................................
Jenis : .......................................... Pantangan : ..............................................
Keluhan : ..........................................
Minum
Frekuensi : .......x/hari, Porsi : ..............................................
Jenis : .......................................... Pantangan : ..............................................
Keluhan : ..........................................
b. Pola eliminasi
BAB
Frekuensi : .......................................... Konsistesi : ..............................................
Warna : .......................................... Keluhan : …..........................................
BAK
Frekuensi : .......................................... Konsistesi : ..............................................
Warna : .......................................... Keluhan : …..........................................
c. Pola istirahat
Tidur siang
Lama : ..... jam/hari, Keluhan : ..............................................
Tidur malam
Lama : ..... jam/hari, Keluhan : ..............................................
d. Pola aktivitas
Pagi-siang :
Malam :
e. Personal hygine
mandi
gosok gigi
keramas

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Program Studi D III Kebidanan Respati

keluhan
f. Seksual
g. Riwayat kesehatan
Penyakit yang pernah /sedang diderita (menular, menurun dan menahun)
1) Sekarang
2) Yang lalu
3) Keluarga
h. Keadan psikososial
1) Pengetahuan ibu tentang KB
2) Dukungan suami/keluarga

2. DATA OBYEKTIF
a. Pemeriksaan umum
Keadaan umum : ....................................
Kesadaran : ....................................
Status emosional : ....................................
TB :
BB :
LILA :
Tanda vital sign :
Tekanan darah :.................mmHg
Nadi : ................ x/menit
Respirasi : ................ x/menit
Suhu : ................ x/menit
b. Pemeriksaan head to too
1) Kepala :
Warna rambut
Kebersihan
Rambut : ......................................................................................................................
Muka : ......................................................................................................................
Mata : ................., sklera ...............................,
konjungtiva ....................................
Hidung : ......................................................................................................................
Mulut : ......................................................................................................................
Telinga : ......................................................................................................................
Leher : ......................................................................................................................
Dada : ......................................................................................................................
Payudara : ......................................................................................................................

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Program Studi D III Kebidanan Respati

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Abdomen : ......................................................................................................................
.....................................................................................................................
Ekstremitas atas : ......................................................................................................................
Ekstremitas bawah : ......................................................................................................................
Genetalia luar : ......................................................................................................................
Anus : ......................................................................................................................
c. Pemeriksaan Penunjang
......................................................................................................................................................
.....................................................................................................................................................
Data Penunjang

II. INTERPRETASI DATA

III. IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL

IV. ANTISIPASI TINDAKAN SEGERA

V. Rencana Asuhan
1. Memberikan KIE
2. Melakukan pemeriksaan pada ibu
3. Lakukan inform consent
4. Siapkan alat KB
5.

VI. Pelaksanaan Jam : ...............WIB, Oleh :.........................

VII. Evaluasi Jam : ...............WIB Oleh :…........

Pembimbing Akademik Pembimbing Lapangan Praktikan

(…………………………...) (……………………………) (……………………………)

LEMBAR OBSERVASI

No. Reg. : .................. Nama pasien :...................... Umur :….. th Nama suami : ..........................
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Pembimbin
g
Akademik
Askeb Nifas
Program Studi D III Kebidanan Respati

G... P... A... Ah... Alamat : ................................................. Masuk tgl/jam:................./..........WIB

Ketuban pecah sejak jam :........WIB Mules sejak jam : …… WIB
HIS NADI SUHU LAIN-LAIN
TGL JAM DJJ Frek. Durasi Kekuatan (TD, Ketuban, PD, Px
(x/10 menit) (detik)
(x/menit) (ºC) Penunjang)