PNC Soap PATOL

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 NIFAS PADA NY.’’.....‘’

DENGAN ………………………………………
DI ...............................................................
Tanggal / waktu pengumpulan data :

Nomor register pasien :
Tempat pengumpulan data :
A. DATA SUBYEKTIF (S)

1. Identitas
Nama Ibu : ......................... Nama Suami :.........................
Umur : ....... Tahun Umur : ....... Tahun
Pendidikan : ......................... Pendidikan : .........................
Agama : ......................... Agama : .........................
Pekerjaan : ......................... Pekerjaan : .........................
Alamat : .....................................................................................
.....................................................................................
2. Keluhan Utama Saat Ini
.............................................................................................................
.............................................................................................................
3. Tanda Bahaya Masa Nifas
a. Demam disertai lochea berbau busuk :........................................
b. Perdarahan > 500 Cc : .......................................
c. Sakit kepala, nyeri epigastrik, : .......................................
penglihatan kabur
d. Demam, muntah, : ................
EKA FEBRIANI INTASARI / P07124018012

e. nyeri saat berkemih
f. Payudara merah, panas, :.......................................
dan terasa sakit
g. Terasa sakit, merah, lunak, : .......................................
dan pembengkakan di kaki
h. Kehilangan nafsu makan dalam : .......................................
Jangka waktu yang lama
i. Perasaan sedih atau tidak mampu : .......................................
Mengurus dirinya dan bayinya
4. Riwayat Persalinan Sekarang

a. Tanggal/jam persalinan: ..............................................................
b. Penolong persalinan : ..............................................................
c. Tempat persalinan : ..............................................................
d. Jenis persalinan (spontan, vakun, SC) : ......................................
e. Keadaan bayi ( BB/PB bayi, Jenis kelamin,
hidup/mati): ...................................................................................
...................
f. Komplikasi selama kehamilan dan persalinan : ..........................
g. Robekan jalan lahir/episiotomi : .................................................
5. Riwayat Persalinan Dan Nifas Yang Lalu

Hami Usia Komplikasi/masala
Tempa Jenis Penolon BBL Usi
l khml JK h Ket
t persl. persl. g (kg) Hamil Persl. Nifas a
Ke- n

6. 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)
1) Frekuensi : ........................................................................
2) Konsistensi : ........................................................................
3) Warna : ........................................................................
4) Kesulitan : ........................................................................
f. Istirahat
1) Kesulitan :........................................................................
g. Ketidaknyamanan Nyeri
1) Lokasi :........................................................................
h. Mobilisasi
1) Duduk :......................................................................
2) Berdiri :......................................................................
3) Berjalan :......................................................................
i. Personal Hygiene
1) Mandi : ...................................................................
2) Gosok gigi : ...................................................................
3) Ganti pakaian : ...................................................................

j. Psikologi
1) Respon Ibu terhadap diri sendiri : ......................................
.............................................................................................
2) Respon Ibu terhadap bayi: .................................................
............................................................................................
3) Respon Kelurga terhadap Ibu dan Bayi : ...........................
............................................................................................
k. Riwayat Sosial Ekonomi
1) Status perkawinan : ................................................
2) Lama perkawinan : ................................................
3) Jumlah anggota kelurga dalam satu rumah: ......................
4) Riwayat dan rencana KB : ................................................
B. DATA OBYEKTIF (O)

1. Pemeriksaan umum
a. Keadaan umum : .............................................................
b. Kesadaran : .............................................................
c. Emosi : .............................................................
2. Tanda vital
a. Nadi : .......... x/menit
b. Suhu : ......... ̊C
c. Tekanan darah : .......... mmHg
d. Respirasi : .......... x/menit
3. Pemeriksaan fisik
a. Kepala
1) Inspeksi : ………………………………………………………….
2) Palpasi : ………………………………………………………….
b. Wajah
1) Inspeksi : ………………………………………………………….
2) Palpasi : ………………………………………………………….
c. Mata : ………………………………………………………….
d. Leher : ………………………………………………………….

e. Payudara dan ketiak
1) Inspeksi : ………………………………………………………….
2) Palpasi :..........................................................................................
f. Abdomen
1) luka bekas operasi : .................................................
2) kandung kemih : .................................................
3) Kontraksi : .................................................
4) TFU : .................................................
5) Massa/konsistensi/otot parut : ................................................
6) Diastasis :................................................
g. Genetalia
1) Keadaan labia mayor dan minor (luka, cairan): ......................
2) perinium (luka laserasi, jahitan perinium) : ......................
3) Lokhia (warna, konsistensi, bau) : .......................
h. Ekstremitas
1) Kemerahan :...............................................
2) Varices :...............................................
3) Tanda homan :...............................................
3. Pemeriksaan penunjang
a. Urine tgl..............
1) Protein Urin : ...................
2) Glukosa urine : ...................
b. Darah tgl..............
1) Hb : ................. gr%
2) Al : .................
3) HMT : .................
4) Golongan Darah : ..............
C. ANALISA
1. Diagnosa : ……………………………………...

2. Masalah : ...........................................................
3. Diagnosa Potensial : ...........................................................
D. PENATALAKSANAAN Tgl/Jam :
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Mengetahui,
Nama Mahasiswa
( ........................................................)
Pembimbing Lahan Pembimbing Pendidikan
(..........................................................) (............................................................)

PNC Soap PATOL

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

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Hak Cipta:

Format Tersedia

PNC Soap PATOL

Diunggah oleh

Hak Cipta:

Format Tersedia

KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

ASUHAN KEBIDANAN NIFAS PADA NY.’’.....‘’

Tanggal / waktu pengumpulan data :

A. DATA SUBYEKTIF (S)

EKA FEBRIANI INTASARI / P07124018012

4. Riwayat Persalinan Sekarang

5. Riwayat Persalinan Dan Nifas Yang Lalu

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

B. DATA OBYEKTIF (O)

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

EKA FEBRIANI INTASARI / P07124018012

Pembimbing Lahan Pembimbing Pendidikan

EKA FEBRIANI INTASARI / P07124018012

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