Lampiran 1

LEMBAR PERSETUJUANMENJADI RESPONDEN

ASUHAN KEPERAWATAN IBU NIFAS MULTIGRAVIDA HARI

PERTAMA DENGAN PARTUS NORMAL DI BPM ASRI DESA
BATURETNO KECAMATAN TUBAN KABUPATEN TUBAN

TAHUN 2019

DITA PUSPITA ARITYAS

NIM.P27820516032

Saya yang bertanda tangan dibawah ini menyatakan untuk turut berpartisipasi
sebagai responden pada studi kasus dengan judul “Asuhan Keperawatan Ibu Nifas
Multigravida Hari Pertama Dengan Partus Normal di BPM Asri Desa Baturetno
Kecamatan Tuban Kabupaten Tuban” yang dilakukan oleh mahasiswa Program
Studi DIII Keperawatan Kampus Tuban Politeknik Kesehatan Kementrian
Kesehatan Surabaya di BPM Asri Desa Baturetno Tuban.

Tanda tangan ini menunjukkan dari saya informasi tentang tujuan penelitian dan
jaminan kerahasiaan tentang identitas saya dan memutuskan untuk berpartisipasi
dalam penelitian ini dengan memeberikan tanggapan sesuai pendapat saya sendiri
tanpa dipengaruhi pihak lain.

Responden No : Ditandatangai di Tuban

Pada Tanggal :
..............................
 Tanda Tangan : .............................
Lampiran 2
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PROGRAM STUDI D III KEPERAWATAN KAMPUS TUBAN
Jl. Wahidin Sudirohusodo 2 Tuban 62314 Telp. (0356) 322184
Fax : (0356) 326898

ASUHAN KEPERAWATAN PADA IBU NIFAS

I. Format Pengkajian :

a. Data Subyektif :

1. Biodata :

Nama klien : ......................... Nama suami : ........................

Umur : ........................
Agama : ........................
Pendidikan : ........................
Pekerjaan : ........................
Penghasilan : ........................
Perkawinan : ........................
Berapa kali : ........................
Lama kawin : ........................
Alamat : ........................
........................
Umur : ........................
Agama : ........................
Pendidikan : ........................
Pekerjaan : ........................
Penghasilan : ........................
Perkawinan : ........................
Berapa kali : ........................
Lama kawin : ........................
Alamat : ........................
........................

2. Keluhan utama :

...............................................................................................................

...............................................................................................................

...............................................................................................................

...............................................................................................................

.........................................................................................................

3. Riwayat penyakit :
 - Penyakit yang pernah diderita

: ..............................................................................................

....

- Penyakit yang sedang diderita :

..................................................................................................

- Pengobatan yang sedang / pernah dilakukan :

..................................................................................................

4. Riwayat kesehatan keluarga :

- Penyakit keturunan : ................................................................

- Penyakit menular dalam keluarga : .......................................

5. Riwayat haid :

- Haid terakhir : ...................................................

- Perkiraan persalinan : ...................................................

- Menarche : ...................................................

- Siklus / lama haid : ...................................................

- Sifat haid / lama darah : ...................................................

- Dysmenorrhoe : ...................................................

- Flour albus : ...................................................

6. Riwayat kontrasepsi :

- Type : ...............................................................

- Kapan menggunakan : .....................................

- Tujuan : .....................................

- Masalah : .....................................
 - Kapan berhenti, alasan : .....................................

- Rencana yang akan digunakan : .....................................

7. Riwayat kehamilan sekarang :

- PNC : .................................... Kali

- Tempat PNC : .............................................................

- Keluhan / kelainan selama kehamilan : ............................

.........................................................................................................

.........................................................................................................

....................................................................................................

- Imunisasi TT : ................................................................

8. Riwayat persalinan sekarang :

- Tanggal persalinan : ................................................................

- Jam : ..................... Persalinan : ....................

- Jam : ..................... Uri lahir :........................

Cotyledon : ...................

- Lama persalinan.

Kala I : ..................................

Kala II : ..................................

Kala III : ..................................

Jumlah : ..................................

- Jumlah perdarahan

:...............................................................................................

.
 - Robekan jalan lahir

: ..............................................................................................

..

- Pengobatan yang diberikan :

...............................................................................................

Kala I : ........................................................................

Kala II : ........................................................................

Kala III : ........................................................................

Kala IV :........................................................................

- Penyulit persalinan : ....................................................

.........................................................................................................

...................................................................................................

- Keadaan bayi :

 Jenis Kelamin : ................................................................

 Umur kehamilan : ...............................................................

 Hidup / mati : ................................................................

 Apgar score : ................................................................

 Berat badan lahir / panjang badan : ................................

 Kelainan : ................................................................

9. Data psikososial
- Status emosi ibu :

.........................................................................................................

.........................................................................................................

.........................................................................................................

....................................................................................................

- Reaksi dan persepsi terhadap kelahiran bayinya :

 Bayi yang diharapkan :

...................................................................................................

.............................................................................................

 Senang menerima / timbul masalah :

...................................................................................................

..............................................................................................

 Sikap / hubungan ibu terhadap bayi :

...................................................................................................

..............................................................................................

- Respon ibu terhadap :

 Perawatan bayi :

...................................................................................................

...................................................................................................

..............................................................................................

 Laktasi :
 ...................................................................................................

..............................................................................................

 Aktivitas / gerak / senam :

...................................................................................................

..............................................................................................

 Keluarga berencana :

..............................................................................................

- Kebutuhan interaksi dengan orang lain :

 Ibu tinggal dirumah dengan siapa :

...................................................................................................

..............................................................................................

 Hubungan dengan anggota keluarga :

...................................................................................................

..............................................................................................

 Hubungan dengan orang lain / masyarakat :

...................................................................................................

..............................................................................................

10. Latar belakang sosial budaya :

(kebiasaan dan kepercayaan sesuai adat istiadat)

...............................................................................................................

.........................................................................................................

11. Hubungan dari keluarga :

 ...............................................................................................................

.........................................................................................................

12. Keadaan sekarang menurut system tubuh :

a. Istirahat tidur :

- Lama tidur : ....................................................

- Kesulitan tidur : ....................................................

b. Personal hygiene :

- Mandi : ......................................

- Perawatan gigi dan mulut : ......................................

- Vulva : ......................................

- Pakaian : ......................................

- Masalah : ......................................

c. Aktivitas gerak :

- Mobilisasi : .............................................................

- Masalah : .............................................................

d. Eliminasi :

- Mictie : .............................................................

- Defacatie : ..............................................................

- Masalah : ..............................................................

13. Pola nutrisi :

- Makanan : ...........................................................................

- Minuman : ...........................................................................

- Pantangan : ...........................................................................
 - Diet khusus : ...............................................................

- Masalah : ...............................................................

b. Data Obyektif

1. Keadaan umum dan tanda-tanda vital.

2. Pemeriksaan fisik

- Keadaan umum : ...............................................................

- Kesadaran : ...............................................................

- Tanda vital : ...............................................................

...............................................................

- Mata : ...............................................................

- Leher : ...............................................................

- Dada / buah dada : ...............................................................

...............................................................

- Perut : ...............................................................

...............................................................

- Kandung kemih : ...............................................................

- Vulva : ...............................................................

...............................................................

...............................................................

- Anus : ...............................................................

- Tungkai : ...............................................................

...............................................................

3. Data penunjang
 - Therapi / instruksi dokter :

.........................................................................................................

.........................................................................................................

...................................................................................................

4. Pemeriksaan laboratorium :

...............................................................................................................

...............................................................................................................

.........................................................................................................

Lampiran 3
 II. Format Interpretasi Data Dasar

Diagnosa / masalah

Tanggal Diagnosa Dasar

Lampiran 4

III. Format Prioritas

 Tanggal Diagnosa Prioritas

Lampiran 5

IV. Format Perencanaaan / Implementasi

Tanggal Diagnosa Perencanaan Implementasi

Lampiran 6

V. Format Evaluasi

Tanggal Diagnosa Evaluasi Paraf

Lampiran 8

KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PRODI DIII KEPERAWATAN KAMPUS TUBAN
 LEMBAR BIMBINGAN PROPOSAL

Nama Dita Puspita Arityas

NIM P27820516032
Nama Pembimbing Teresia Retna P, S.Kep.,Ns.,M.Kes
Judul KTI Asuhan Keperawatan Ibu Nifas Multigravida Hari
Pertama Dengan Partus Normal di BPM Asri Desa
Baturetno Kecamatan Tuban Kabupaten Tuban

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN
Lampiran 8

KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PRODI DIII KEPERAWATAN KAMPUS TUBAN

LEMBAR BIMBINGAN PROPOSAL

Nama Dita Puspita Arityas
NIM P27820516032
Nama Pembimbing Yasin Wahyurianto, S.Kep.,Ns.,M.Si
Judul KTI Asuhan Keperawatan Ibu Nifas Multigravida Hari
Pertama Dengan Partus Normal di BPM Asri Desa
Baturetno Kecamatan Tuban Kabupaten Tuban

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN
Lampiran 8

KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PRODI DIII KEPERAWATAN KAMPUS TUBAN

LEMBAR BIMBINGAN PROPOSAL

Nama Dita Puspita Arityas

NIM P27820516032
Nama Pembimbing Hadi Purwanto, S.Kep.,Ns.,M.Kes
Judul KTI Asuhan Keperawatan Ibu Nifas Multigravida Hari
Pertama Dengan Partus Normal di BPM Asri Desa
Baturetno Kecamatan Tuban Kabupaten Tuban

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN
Lampiran 8

KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PRODI DIII KEPERAWATAN KAMPUS TUBAN

LEMBAR BIMBINGAN PROPOSAL

Nama Dita Puapita Arityas

NIM P27820516032
Nama Pembimbing Teresia Retna P, S.Kep.,Ns.,M.Kes
Judul KTI Asuhan Keperawatan Ibu Nifas Multigravida Hari
Pertama Dengan Partus Normal di BPM Asri Desa
Baturetno Kecamatan Tuban Kabupaten Tuban

NO TANGGAL MATERI PARAF

BIMBINGAN BIMBINGAN

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Lampiran 8

KEMENTERIAN KESEHATAN RI
POLTEKKES KEMENKES SURABAYA
JURUSAN KEPERAWATAN
PRODI DIII KEPERAWATAN KAMPUS TUBAN

LEMBAR REFISI PROPOSAL

Nama Dita Puspita Arityas

NIM P27820516032
Nama Pembimbing Teresia Retna P, S.Kep.,Ns.,M.Kes
Judul KTI Asuhan Keperawatan Ibu Nifas Multigravida Hari
Pertama Dengan Partus Normal di BPM Asri Desa
Baturetno Kecamatan Tuban Kabupaten Tuban

NO PENGUJI MATERI PARAF

BIMBINGAN

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