ASUHAN KEBIDANAN IBU NIFAS

Ruang : ................................
Tanggal : .................................

I. PENGKAJIAN
Identitas/Biodata
Nomor RM : ..........................
Nama Ibu : .......................... Nama Suami : ..........................
Umur : .......................... : ..........................
Pendidikan : .......................... : ..........................
Pekerjaan/Penghasilan : .......................... : ..........................
Suku/Bangsa : .......................... : ..........................
Agama : .......................... : ..........................
Alamat: .......................... : ..........................

Anamnesa pada tanggal .......................................................Pukul ....................................

1. Keluhan utama/Alasan datang: ..................................................................................

2. Riwayat Kehamilan dan Persalinan saat ini:
a. Para : A: Hidup :
b. Masa Gestasi : ......................................................................................................
c. Kelaianan selama hamil : .....................................................................................
d. Tanggal persalinan : .....................................................................................
e. Tempat persalinan : .....................................................................................
f. Penolong persalinan : .....................................................................................
g. Jenis persalinan : .....................................................................................
h. Ketuban pecah : .....................................................................................
i. Lama persalinan : .....................................................................................
j. Perdarahan : .................................................................................
....
k. Penyulit dalam persalinan : .....................................................................................
l. Plasenta : .....................................................................................
m. Perineum : .....................................................................................
n. Anak : ..........., BB : ................ gram, PB:.........cm, Kelainan
bawaan: ....................................
o. Obat-obat yang diperoleh selama nifas: ................................................................
3. Rawat gabung: ........, alasan: .....................................................................................
4. Riwayat perkawinan :
 a. Status perkawinan : .................................................
b. Usia pertama kali menikah : .................................................
c. Berapa kali menikah : .................................................
d. Lama menikah dengan suami sekarang : .................................................
e. Anak dari pernikahan yang sekarang atau yang lalu : ..........................................
5. Riwayat kesehatan :
a. Riwayat kesehatan sekarang:
.........................................................................................................................................
.........................................................................................................................................
.....................................................................................................................
b. Riwayat kesehatan yang lalu
: .................................................................................................................................
.........................................................................................................................................
.............................................................................................................................
c. Riwayat kesehatan keluarga
: .................................................................................................................................
.........................................................................................................................................
.............................................................................................................................
6. Riwayat obstetrik yang lalu:

Tgl lahir/ Bayi nifas

Penyulit Jenis Tempat Komplikasi Penolong
No umur PB/BB,
kehamilan persalinan persalinan persalinan persalinan Keadaan Keadaan Laktasi
anak Kelamin

7. Riwayat KB :

Jenis/Sejak Lama Penggunaan Keluhan Alasan Berhenti

8. Pola Pemenuhan Kebutuhan Sehari-hari:

pantangan atau
Kebutuhan Keluhan
kekhawatiran

Nutrisi :
 Makan
(................................................................)
 Minum
(................................................................)
Eliminasi :
 BAK
(................................................................)
 BAB
(................................................................)
Istirahat
(................................................................
................................................................)

Aktifitas
(................................................................)

Personal Hygien
(................................................................)

Rekreasi
(................................................................)

Pola Seksual
(................................................................)

9. Data Psikologis :
a. Tanggapan ibu atas kelahiran bayinya/jenis kelamin bayinya:
.............................................................................................................................
b. Perasaan ibu atas peran barunya:
..............................................................................................................................
c. Perasaan ibu terhadap penampilan diri di hadapan suami:
...............................................................................................................................
d. Keyakinan ibu atas kemampuan menjadi ibu :
...............................................................................................................................
e. Tanggapan keluarga atas kelahiran bayinya:
 ...............................................................................................................................
f. Tanggapan anak sebelumnya atas kelahiran bayinya: ..........................................
g. Rencana ibu menyusui bayinya:
..............................................................................................................................
10. Data Sosial-Budaya :
a. Hubungan dengan suami, dan anggota keluarga lain:
.............................................................................................................................
b. Hubungan dengan tetangga:
.............................................................................................................................
c. Hewan peliharaan: ..............................................................................................
d. Lingkungan: ..........................................................................................................
e. Adat/tradisi/kebiasaan dalam masa nifas bagi ibu dan bayi: ................................
11. Data spiritual : ................................................................................................
12. Pengetahuan ibu :
a. Masa nifas : ...........................................................................................................
b. Nutrisi & cairan : ..................................................................................................
c. Mobilisasi/latihan/senam: .....................................................................................
d. Eliminasi: ................................................................................................................
e. Hygiene diri dan perineum: ...................................................................................
f. Istirahat: ...............................................................................................................
g. Seksualitas: ...........................................................................................................
h. Kontrasepsi: ibu ...................................................................................................
i. Tanda bahaya masa nifas: ...................................................................................
j. Jadwal kunjungan: ................................................................................................
13. Pengetahuan tentang bayi:
a. Tentang menyusui/makanan bayi:
1) Manfaat ASI : ................................................................................................
2) Makanan bati ( ASI eksklusif): .........................................................................
3) Perawatan payudara: ....................................................................................
4) Teknik menyusui dengan benar ( 1 atau 2 bayi): ...........................................
b. Tentang bayi:
1) Perawatan bayi sehari-hari: ...........................................................................
2) Imunisasi dasar bayi: .....................................................................................
3) Metode pencegahan hipotermi: ......................................................................

II. PEMERIKSAAN UMUM

1. Pemeriksaan umum
a. Keadaan Umum : .................................................................................................
 b. Kesadaran : .................................................................................................
c. Status Emosional : .................................................................................................
d. Tanda vital :
 TD : .................................................................................................
 Nadi : .................................................................................................

 RR : .................................................................................................

 Suhu : .................................................................................................

e. Status present
 Kepala
 Rambut : .................................................................................................
 Muka : .................................................................................................
 Mata : .................................................................................................
 Hidung : .................................................................................................
 Telinga : .................................................................................................
 Mulut : .................................................................................................
 Leher : .................................................................................................
 Dada : .................................................................................................
 Mammae : .................................................................................................
 Perut : .................................................................................................
 Genetalia : .................................................................................................
 Ekstremitas
 Atas : .................................................................................................
 Bawah : .................................................................................................
2. Pemeriksaan Obstetri
 Wajah/muka : .................................................................................................
 Payudara:
a) Bentuk : .................................................................................................
b) Putting : .................................................................................................
c) Pengeluaran: .................................................................................................
d) Pembengkakan: .................................................................................................
e) Lain-lain: .................................................................................................
 Abdomen:
a) Tinggi fundus uteri: .........................................................................................
b) Kontraksi uterus: .............................................................................................
c) Palpasi supra publik/kandung kemih: .............................................................
 d) Lain-lain: .................................................................................................

 Pengeluaran pervaginam:
a) Warna lochea : .................................................................................................
b) Banyaknya: .................................................................................................
c) Bau: .................................................................................................
d) Lain-lain: .................................................................................................
 Perineum dan anus:
a) Luka episiotomi/jahitan: .................................................................................
b) Keadaan luka: .................................................................................................
c) Tanda radang: .................................................................................................
d) Keadaan vulva: ...............................................................................................
e) Anus: .................................................................................................
2. Pemeriksaan Penunjang / laboratorium
a. Protein urin : .................................................................................................
b. Urin reduksi : .................................................................................................
c. HB : .................................................................................................
d. Terapi : .................................................................................................