ASUHAN KEPERAWATAN PADA IBU NIFAS

Nama Mahasiswa :
NIM :
Tanggal Pengkajian :
Ruang / RS :

Tanggal Masuk : ........................................... Tanggal Pengkajian : .....................................

Jam Masuk : ........................................... Jam Pengkajian : .....................................
Tempat : ...........................................

I. DATA UMUM KLIEN

A. Data Subjektif
1. Biodata
IBU PENANGGUNG JAWAB
Nama : .............................................. Nama : ..........................................
Umur : .............................................. Umur : .........................................
Agama : .............................................. Agama : .........................................
Suku/ Bangsa: .............................................. Suku/ Bangsa : .........................................
Pendidikan : .............................................. Pendidikan : .........................................
Pekerjaan : .............................................. Pekerjaan : .........................................
Alamat : .............................................. Alamat : .........................................

2. Alasan Utama/ Alasan Masuk

……………………………………………………............................................................................
……………………………………………………............................................................................
……………………………………………………............................................................................
……………………………………………………............................................................................

3. Riwayat Menstruasi
Menarchea : .....................................................................................................
Siklus : .....................................................................................................
Lama menstruasi : .....................................................................................................
Banyaknya ganti pembalut : .....................................................................................................
Dismenorhea : .....................................................................................................

4. Riwayat Kehamilan, Persalinan, dan Nifas Yang Lalu

Anak Tanggal lahir/ Jenis Tempat Komplikasi Bayi Nifas

UK Penolong
ke- umur Persalinan Persalinan
Bayi Ibu PB/ BB Keadaan Keadaan Laktasi
 5. Riwayat Persalinan Sekarang
Tanggal/Jam Persalinan : ......................................................................................................
Tempat Persalinan : ......................................................................................................
Penolong Persalinan : ......................................................................................................
Jenis Persalinan : ......................................................................................................
Komplikasi Persalinan : ......................................................................................................
Keadaan Plasenta : ......................................................................................................
Tali Pusat : ......................................................................................................
Lama Persalinan : Kala I ............ Kala II ............ Kala III ............ Kala IV ............
Jumlah Perdarahan : ......................................................................................................
Bayi : BB: ..................... PB: ..................... Apgar Score: .....................
Cacat Bawaan: ............................................................................
Masa Gestasi : ............................................................................

6. Riwayat Keehatan Sekarang/ Yang Lalu

Jantung : ....................................................................................................................
Hipertensi : ....................................................................................................................
Diabetes Melitus : ....................................................................................................................
Ginjal : ....................................................................................................................
Asma : .....................................................................................................................
Hepatitis : .....................................................................................................................
Lain-lain : .....................................................................................................................

7. Riwayat Operasi Abdomen/ SC

Tempat : .................................................................................................................................
Penolong : .................................................................................................................................
Tanggal : .................................................................................................................................

8. Riwayat Penyakit Keluarga

Jantung : ....................................................................................................................
Hipertensi : ....................................................................................................................
Diabetes Melitus : ....................................................................................................................
Hepatitis : .....................................................................................................................
Asma : .....................................................................................................................
Ginjal : ....................................................................................................................
Riwayat bayi kembar: ....................................................................................................................

9. Riwayat KB
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

10. Riwayat Sosial, Ekonomi dan Psikologis

Status Perkawinan : .........................................................................................................
Berapa kali kawin : .........................................................................................................
Lama menikah : .........................................................................................................
Umur menikah pertama kali : .........................................................................................................
Kehamilan ini : Direncanakan / Tidak direncanakan
 Perasaan ibu dan keluarga terhadap kehamilan : ....................................................................
Pengambilan keputusan dalam keluarga : ....................................................................

11. Riwayat Psikosisal

Taking In : .................................................................................................................................
Taking Hold : .................................................................................................................................
Letting Go : .................................................................................................................................

12. Activity Daily Living

1) Pola makan dan minum
Frekuensi : .....................................................................................................
Jenis : .....................................................................................................
Porsi : .....................................................................................................
Keluhan/ pantangan : .....................................................................................................
2) Pola istirahat
Tidur siang : .................................................................................................................
Tidur malam : .................................................................................................................
Keluhan : .................................................................................................................
3) Pola eliminasi
BAK : .......... kali/ hari Konsistensi: ......................... Warna: ...............................
BAB : .......... kali/ hari Lendir/ darah: ...................... Warna: ..............................
4) Personal hygiene
Mandi : .....................................................................................................
Ganti pakaian : .....................................................................................................
Ganti pakaian dalam : .....................................................................................................
5) Mobilisasi
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
6) Aktivitas
Pekerjaan sehari- hari : .....................................................................................................
Keluhan : .....................................................................................................
Hubungan seksual : .....................................................................................................
7) Menyusui
Keluhan : .....................................................................................................
8) Kebiasaan hidup
Merokok : .....................................................................................................
Minum- minuman keras : .....................................................................................................
Konsumsi obat terlarang : .....................................................................................................
Minum jamu : .....................................................................................................

B. Data Objektif
1. Keadaan umum : .................................................................................................................
Tingkat kesadaran : .................................................................................................................

2. Tanda- tanda Vital

Tekanan darah : ..................... mmHg
Nadi : ..................... kali/ menit
Suhu : .....................
 Respirasi : ..................... kali/ menit
Tinggi badan : ..................... cm
Berat bdan : ..................... kg
LILA : ..................... cm

3. Pemeriksaan fisik
1) Inspeksi : .................................................................................................................
Postur tubuh : .................................................................................................................
Kepala : .................................................................................................................
Rambut : .................................................................................................................
Muka : .................................................................................................................
Mata : .................................................................................................................
Hidung : .................................................................................................................
Gigi dan mulut : .................................................................................................................
Telinga : .................................................................................................................
2) Leher
...............................................................................................................................................
...............................................................................................................................................
3) Payudara
Bentuk : .....................................................................................................
Keadaan puting susu : .....................................................................................................
Aerola mame : .....................................................................................................
Colostrum : .....................................................................................................
4) Abdomen
Pembesaran perut sesuai dengan usia kehamilan : ya / tidak
Linea nigra : .....................................................................................................
Bekas luka/ operasi : .....................................................................................................
5) Genetalia
Varises : .........................................................................................
Odema : .........................................................................................
Pembesaran kelenjar bartholini : .........................................................................................
Pengeluaran pervaginam : .........................................................................................
Bekas luka/ jahitan perineum : .........................................................................................
Bau : .........................................................................................
Anus : .........................................................................................
Hemeroid : ada / tidak
6) Ekstremitas
Kesimetrisan : .........................................................................................
Odeme pada tungkai bawah : .........................................................................................
Varises : .........................................................................................
Pergerakan : .........................................................................................
II. PEMERIKSAAN PENUNJANG
1. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
2. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
3. Pemeriksaan Lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

Jombang, ………………………….2021
Mengetahui
Mahasiswa
Pembimbing Klinik

(……………………………………….) Sabrina Kumala Dewi

NIP. ………………………………. NIM. P17212215040
 ANALISIS DATA

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 DIAGNOSIS KEPERAWATAN

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 INTERVENSI KEPERAWATAN

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 TINDAKAN KEPERAWATAN DAN EVALUASI

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