FORMAT ASKEB PADA IBU NIFAS

No MR :

Masuk tgl/jam :

I. PENGKAJIAN Tgl/jam.............................................
A. DATA SUBJEKTIF
1. Identitas Istri Suami
Nama : ............................................. ..........................................
Umur : ............................................. ..........................................
Agama : ............................................. ..........................................
Pendidikan : ............................................. ..........................................
Pekerjaan : ............................................. ..........................................
Suku / bangsa : ............................................. ..........................................
Alamat : ............................................. ..........................................
Telp : ............................................. ..........................................
2. Anamnesa
a. Keluhan Utama
..............................................................................................................................
b. Riwayat Perkawinan
Perkawinan ke ................................. menikah sejak umur .............................
lamaperkawinan ............................................. status...........................................
c. Riwayat Haid
Menarche........................................................HPM.............................................
HPL................................................................lama...............................................
Teratur / tidak................................................sakit / tidak....................................
Siklus....................................................................................................................
 d. Riwayat Obstertic
G........P.......A...........Ah............

Jenis BB
No Th Penolong Tempat H/M J/K Komplikasi Ket
Persalinan lahir

d. Riwayat KB

PASANG LEPAS
No
Metode Tgl Petugas Tempat Tgl Petugas Tempat Alasan

e. Riwayat Kesehatan
1). Riwayat Kesehatan Yang Lalu
........................................................................................................................
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2). Riwayat Kesehatan Sekarang
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3). Riwayat Kesehatan Keluarga
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f. Riwayat persalinan terakhir
KALA LAMA TINDAKAN PERDARAHAN KET

g. Pola Kebutuhan Sehari-hari

1). Nutrisi
Porsi makan sehari : ............................................................................
Jenis : ............................................................................
Makanan pantang : ............................................................................
 Pola minum : ............................................................................
Masalah : ............................................................................
2). Eliminasi
a). BAK
Frekuensi................................jumlah...........................warna..................
Keluhan....................................................................................................
b). BAB
Frekuensi................................jumlah...........................warna..................
Keluhan....................................................................................................
3). Istirahat
Siang..........................................................malam..........................................
Keluhan..........................................................................................................
4). Aktivitas :.........................................................................................
5). Personal higiene :.........................................................................................
..........................................................................................
6). Pola seksual :.........................................................................................
h. Data Psikososial Spiritual
Tanggapan ibu dan keluarga pada masa
nifas......................................................................................................................
Pengetahuan ibu dan keluarga tentang masa
nifas......................................................................................................................
Pengambilan keputusan oleh :.............................................................................
Ketaatan ibu beribadah :.............................................................................
Ibu tinggal beribadah :.............................................................................
Hewan piaraan :.............................................................................
B. DATA OBJEKTIF
1. Pemeriksaan umum
KU :.................................................................................................................
Kesadaran :.................................................................................................................
TB :................................................................................................................
BB :sebelum hamil..........................sekarang.................................................
LILA : ................................................................................................................
Vital sighn : ................................................................................................................
 2. Pemeriksaan obstetrik
Kepala : ...................................................................................................................
.....................................................................................................................
Muka : ...................................................................................................................
.....................................................................................................................
Mata : ...................................................................................................................
.....................................................................................................................
Leher : ...................................................................................................................
.....................................................................................................................
Aksila : ...................................................................................................................
.....................................................................................................................
Payudara : ...................................................................................................................
..................................................................................................................
Abdomen: ..................................................................................................................
.....................................................................................................................
Genetalia : ...............................................................................................................
........................................................................(isnpekulo bila dilakukan)
Ektermitas:.................................................................................................................
............................................................................................ (reflekpatela kanan/kiri)
3. Pemeriksaan penunjang
a. Urine :tgl................................................................(pp test,protein,glukosa,dll)
..................................................................................................................
b. Darah :tgl............................................................(Hb,Al,HMT,golongan darah)
..................................................................................................................
C. ANALISA DATA
1. Diagnosa kebidanan:
..........................................................................................................................................
..........................................................................................................................................
Data dasar
DS : ............................................................................................................................
....................................................................................................................................
DO: ............................................................................................................................
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1. Diagnosa masalah:
..........................................................................................................................................
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Data dasar :
DS: .............................................................................................................................
....................................................................................................................................
DO: ............................................................................................................................
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D. PENATALAKSANAAN
Tanggal: Jam:

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