POLTEKNIK KESEHATAN KEMENKES BANDUNG

PROGRAM STUDI KEBIDANAN KARAWANG

Jalan Kertabummi No. 74

FORMAT PENGKAJIAN POSTNATAL CARE

No. Register : Tanggal/Waktu Pengkajian :

Nama Pengkaji : Tempat Pengkajian :
Kunjungan : Pertama/Ulang

I. PENGKAJIAN DATA SUBJEKTIF (S)

A. BIODATA
Nama Klien : Nama Suami :
Umur : Umur :
Suku Bangsa : Suku Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Golongan darah : Golongan darah :
Alamat rumah : Alamat rumah :

Status Perkawinan :
Perkawinan ke- :
Lama Perkawinan :

B. KELUHAN : ........................................................................................................................... ....................................

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C. RIWAYAT KEHAMILAN DAN PERSALINAN SEKARANG

1. Riwayat Kehamilan
Umur Kehamilan : .....................................................................................................................................
Penyulit : ....................................................................................................................................
2. Riwayat Persalinan
Kala I : .....................................................................................................................................
Kala II : .....................................................................................................................................
Kala III : ....................................................................................................................................
Kala IV : ....................................................................................................................................
Penyulit : ...................................................................................................................................

D. RIWAYAT KEHAMILAN DAN PERSALINAN YANG LALU

Tanggal Persalinan Nifas
No. JK Penolong Ket.
Melahirkan Jenis BB PB Tempat Lochea Infeksi Laktasi

E. RIWAYAT KESEHATAN
1. Riwayat penyakit yang pernah diderita : .................................................................................
2. Riwayat penyakit yang sedang diderita : .................................................................................
3. Riwayat penyakit keluarga : .................................................................................
4. Riwayat operasi : .................................................................................
5. Riwayat alergi : .................................................................................

F. Riwayat kontrasepsi
Jenis kontrasepsi : ..............................................................................................................
Alasan : ..............................................................................................................
Mulai : ..............................................................................................................
Terakhir : ..............................................................................................................
Lama pemakaian : ..............................................................................................................
Tempat Pelayanan : ..............................................................................................................
Keluhan : ..............................................................................................................
Rencana KB yang akan datang : ..............................................................................................................
G. POLA AKTIVITAS SEHARI-HARI
1. Diet
a. Kebutuhan Nutrisi
1) Pola makan : .........................................................................................
2) Porsi makan : .........................................................................................
3) Jenis makanan yang dikonsumsi : .........................................................................................
4) Makanan yang dipantang : .........................................................................................
5) Perubahan pola makan : .........................................................................................
6) Alergi terhadap makanan : .........................................................................................
b. Hidrasi
1) Jenis cairan yang diminum sehari : .........................................................................................
2) Jumlah cairan yang diminum sehari : .........................................................................................
2. Istirahat dan Tidur
a. Tidur siang : ......................... jam/hari
b. Tidur malam : ......................... jam/hari
c. Masalah : ............................................................
3. Personal Hygiene
Mandi : ......................... x/hari
Gosok gigi : ......................... x/hari
Ganti pembalut : ......................... x/hari
Vulva hygiene : ......................... x/hari
Ganti pakaian dalam : ......................... x/hari
Ganti pakaian : ......................... x/hari
4. Aktivitas Seksual
Rencana hubungan seksual : ............................................................
Alasan : ............................................................
5. Eliminasi
BAK : ......................... x/hari
Banyaknya : ......................... cc
Masalah : ............................................................
BAB : ......................... x/hari
Konsistensi : ............................................................
Masalah : ............................................................
6. Perilaku kesehatan
a. Obat-obatan yang sedang dikonsumsi : .........................................................................................
b. Obat-obatan yang pernah dikonsumsi : .........................................................................................
c. Obat-obatan terlarang : .........................................................................................
d. Alkohol : .........................................................................................
e. Merokok : .........................................................................................
7. Aktivitas dan Mobilisasi
a. Aktivitas yang dusah dilakukan : .........................................................................................
b. Mobilisasi : .........................................................................................

H. Keadaan Psikologis dan Sosial

1. Keadaan psikologis
2. Hubungan dengan suami
3. Hubungan dengan anggota keluarga lain
4. Tanggapan keluarga atas kelahiran bayi
5. Hubungan dengan lingkungan
6. Keadaan spiritual
7. Tanggapan ibu terhadap kelahiran anak
8. Rencana ibu menyusukan bayi
9. Anggota keluarga yang tinggal serumah
No. Nama L/P Usia
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
: .........................................................................................
Hubungan Keluarga Pendidikan Pekerjaan Ket.
II. PENGKAJIAN DATA OBJEKTIF (O)
A. Keadaan Umum : ....................... Kesadaran : ............................. Status Emosional : .....................
B. Tanda-tanda vital
Tekanan Darah : ............. mmHg Nadi : ............ kali/menit, regular/irregular
Respirasi : .............kali/menit, regular/irregular Suhu : ........... oC
C. Berat badan : Kg
D. Pemeriksaan Fisik
1. Kepala
Inspeksi : Warna rambut : .................... Kebersihan : ...............................
Palpasi : Keadaan rambut : rontok/tidak Benjolan : ada/tidak
2. Muka
Inspeksi : Simetris : ............................... Pucat atau tidak : ...............................
Palpasi : Oedema : ...............................
3. Mata
Simetris : ................................................. Sklera : .................................................
Konjungtiva : ................................................. Kelainan : .................................................
4. Hidung
Kebersihan : .................................................
Polip : .................................................
Kelainan : .................................................
5. Telinga
Simetris : .................................................
Kebersihan : .................................................
Kelaianan : .................................................
6. Mulut
Warna : .................................................
Lidah : .................................................
Warna gigi : .................................................
7. Leher
Pembengkakan kelenjar thyroid : .................................................
Pembengkakan KGB : .................................................
Pembengkakan vena jugularis : .................................................
8. Dada
Jantung : Irama : regular/irregular/gallop/mur-mur
Paru-paru : Bunyi : bersih/ronchii/wheezing
Payudara
Inspeksi : Simetris/tidak : .................................................
Benjolan : .................................................
Hyperpigmentasi : .................................................
Palpasi : Benjolan : .................................................
Puting susu : .................................................
Colostrum : .................................................
Pembesaran KGB Axila : .................................................
9. Abdomen
Inspeksi : Bentuk perut : .................................................
Sikatrik bekas operasi : .................................................
Striae : .................................................
Hyperpigmentasi : .................................................
Palpasi : TFU : .................................................
Diastasis Rekti : .................................................
Konsistensi uterus : .................................................
10. Ekstremitas atas
Oedema : Ya/Tidak
Capillary refill : .................................................
11. Ekstremitas bawah
Bentuk : .................................................
Oedema : Ya/Tidak
Varises : .................................................
Reflex patella : .................................................
Capillary refill : .................................................
Tanda homan : .................................................
12. Genetalia
Inspeksi : Oedema : .................................................
Varises : .................................................
 Pembesaran kelenjar bartholin : .................................................
Pengeluaran : .................................................
Luka perineum : .................................................
Keadaan luka perineum : .................................................
Palpasi : Oedema : .................................................
Varises : .................................................
Pembesaran kelenjar bartholin : .................................................
Pengeluaran : .................................................
Luka perineum : .................................................
13. Anus
Haemorroid : ada/tidak
E. Pemeriksaan Laboratorium
1. Darah
Hb : .................... gr%
Leukosit : ....................
GDS : ....................
2. Urine
Protein Urine : ....................
Glukosa Urine : ....................
F. Pemeriksaan Penunjang
1. Ultrasonografi USG : ........................................
2. Rongent : ........................................
3. Mammogram Mammografi : ........................................
4. Lain-lain : ........................................

III. ASSESMENT (A)

Diagnosa : .....................................................................................................................................
............................................................................................................................. ........
Masalah potensial : .....................................................................................................................................
Antisipasi masalah potensial : .....................................................................................................................................

IV. PLANNING (P)

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