KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI D-IV KEBIDANAN KEDIRI
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website : http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email : direktorat@poltekkes-malang.ac.id Kediri 64114

FORMAT ASUHAN KEBIDANAN PADA IBU NIFAS (PNC)

PENGKAJIAN

Tanggal : 4 April 2020 Jam : 10.00

No. RM :
Nama : Ny. Y Nama Suami : Tn. T
Umur : 28 Umur : 29
Agama : Islam Agama : Islam
Pendidikan : SMA Pendidikan : SMA
Pekerjaan : IRT Pekerjaan : Wiraswasta
Alamat : Jalan Adi Sucipto No. 29 Alamat : Jalan Adi Sucipto No. 29

Cara masuk :
Datang Sendiri Rujukan dari :
Diagnose :
A. DATA SUBYEKTIF
1. Keluhan utama : Ibu mengeluh 7 hari setelah melahirkan anak ke 2 payudara merasa
nyeri dan bengkak, payudara kemerahan, demam
2. Riwayat menstruasi
 Usia manarche : 12 tahun
 Jumlah darah haid : 3x ganti pembalut per hari
 HPHT :
 Keluhan saat haid : tidak ada
 Lama haid : 7-8 hari
 Flour albus : tidak ada
 TP :
 Keluhan haid :tidak ada

Disminorhoe Spoting Menorrhagia Premenstrual syndrome

Dll..............
3. Riwayat kehamilan,persalinan, dan nifas yang lalu.
G............................p.............................A.........................Hidup..............................

No. Tgl, Th Tempat Umur Jenis Penolong Penyulit Anak Keadaan

partus partus kehamilan Kelamin persalina JK/BB anak
 n sekarang

4. Riwayat kesehatan penyakit yang pernah diderita :

 Anemia
 Hipertensi
 Kardiovaskular
 TBC
 Diabetes
 Malaria
 IMS (Sphilis, GO, HIV/AIDS, dll)
 Lain-lain....

Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................

Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
Lain-lain

5. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :

Ibu dan keluarga tidak ada riwayat penyakit

6. Status perkawinan : ya/tidak

Kawin 1 kali, kawin usia 23 tahun, lama menikah 5 tahun

7. Riwayat psiko sosial ekonomi

- Respon ibu dan keluarga terhadap kehamilan

Ibu dan keluarga senang dengan hadirnya anak ke 2 ini

- Penggunaan alat kontrasepsi KB

Ibu menggunakan kontrasepsi suntik

- Dukungan keluarga

Keluarga mendukung dengan anak kedua

- Pengambilan keputusan dalam keluarga

Suami berdiskusi dengan ibu

- Gizi yang dikonsumsi dan kebiasaan makan
 Ibu makan 3 kali sehari dengan sayur, tempe, telur, ikan kadang makan buah
- Kebiasaan hidup sehat

Ibu mandi 2 kali sehari, gosok gigi, ganti baju, dan cuci tangan sebelum makan
- Beban kerja sehari

Ibu melakukan pekerjaan rumah

- Tempat dan penolong persalinan yang diinginkan

Bidan
- Penghasilan keluarga

Rp 2.800.000

8. Riwayat KB dan rencana KB

Metode yang pernah dipakai : suntik , Lama : 2 tahun bulan/tahun

Komplikasi dari KB : tidak ada , Rencana KB selanjutnya: suntik

9. Riwayat Ginekologi :

Infertilitas Infeksi virus PMS Endometritis

Polip serviks Kanker kandungan Operasi kandungan Perkosaan
DUB dll........................
10. Pola makan / minum/ eliminasi/ istirahat
- Pola minum : 8gelas/hari
- Pola eliminasi :

BAK 7 kali/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK terakhir jam :

08.00
BAB 1 kali/hari, karakteristik: lembek/keras, BAB terakhir jam :05.00
- Pola istirahat :8 jam/hari, tidur terakhir jam : 20.30
- Dukungan keluarga : Suami Orang tua Mertua Keluarga lain

B. DATA OBYEKTIF
1. Pemeriksaan umum

Keadaan umum : baik Kesadaran : composmentis

BB/TB : 60/160 Tekanan Darah: 110/70
Nadi : 90x/menit Suhu : 35℃
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
 Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum

Puting susu menonjol/masuk ke dalam

- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema

Reflek patella varises

3. Pemeriksaan khusus
a. Abdomen

Inspeksi membesar dengan arah memanjang melebur

linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
b. TFU : .............................., Kontraksi Uterus : Baik/lembek

Diastesis rectus abdomonis : +/-, ............................

Kandung kemih : Kosong/ penuh
Vulva Vagina : Lochea.................., Bau +/-
Luka Jalan lahir : Ruptur/Episiotomi, bengkak/tidak, bersih/kotor, luka
jahitan bertaut/tidak, basah/kering
Tanda-tanda Reeda (Red, Echimosis, Edema, Discharge, Aproximal)
Ekstremitas : Tromboflebitis (ada/tidak, berapa lama....................)

4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................

C. ANALISA / INTEPRETASI DATA

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D. PENATALAKSANAAN

Tanggal : ....................................................... Jam : ..........................

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Kediri,............................
 Pembimbing Praktik Mahasiswa

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NIP. NIM.

Dosen Pembimbing

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NIP.