MODUL PEMBELAJARAN

DOKUMENTASI KEBIDANAN

Oleh:
Umi Laelatul Qomar, S.ST, MPH
Kusumastuti, S.Si.T., M.Kes
Eni Indrayani., S.Si.T., MPPH

Prodi Kebidanan Program Diploma III 2021/2022

0|Dokumentasi
 CONTOH FORMAT ASUHAN IBU HAMIL DG POLA PIKIR VARNEY

ASUHAN KEBIDANAN PADA IBU HAMIL FISIOLOGIS TRIMESTER ...

Ny. ... UMUR ..... G... P... A... UMUR KEHAMILAN ......... MINGGU (Dibulatkan)
DI..........................................................................

I. PENGKAJIAN
Hari/ Tanggal : .....................................
Jam : .....................................
No.Register : .....................................

A. IDENTITAS
KLIEN SUAMI
Nama Ibu : .................................. ...................................
Umur : …………………….. ……………………...
Suku Bangsa : …………………….. ……………………...
Agama : .................................. ...................................
Pendidikan : .................................. ...................................
Pekerjaan : .................................. ...................................
Alamat : .................................. ...................................

B. SUBJEKTIF
1. Alasan Datang :
.........................................................................................................................
2. Keluhan Utama :
.........................................................................................................................
3. Riwayat Menstruasi
Menarche umur : ........................................................................................
Siklus : ........................................................................................
Lama : ........................................................................................
Volume : ........................................................................................
Konsistensi : .........................................................................................
Warna darah : .........................................................................................

1|Dokumentasi
 Keluhan (fluor albus, dismenorea) :
……………………………………………………..........
4. Riwayat Kehamilan Sekarang
GPA : ………………………
HPHT : ……………………… HPL:.......................... UK:.............
a. Kehamilan Trimester I
Tanggal PP Test : ………………………
Hasil : ………………………
Dilakukan oleh : ....................................
Keluhan/masalah : ....................................
Penggunaan obat- obatan dan jamu- jamuan: ...................................
b. Kehamilan Trimester II
Frekuensi pemeriksaan : ...................................
Mulainya gerakan janin : ...................................
Keluhan/masalah yang dirasakan : ...................................
Imunisasi TT : ...................................
c. Kehamilan Trimester III
Frekuensi pemeriksaan : ...................................
Pergerakan janin dalam 12 jam terakhir : ...................................
Keluhan/masalah yang dirasakan : ...................................
5. Riwayat Kehamilan, Persalinan dan Nifas yang lalu
G1 P0 A0
N Kehamilan Persalinan Nifas Ket (anak
o hidup/mati,
Jenis

Penolong

Jk

BB

PB

Masalah

Lochea

laktasi

Masalah

usia anak skrg

6. Riwayat Kesehatan
a. Dahulu
…………………………………………………………………………
b. Sekarang
…………………………………………………………………………
c. Keluarga
2|Dokumentasi
 …………………………………………………………………………
7. Riwayat Perkawinan
a. Usia menikah : …………………………………………………......
b. Status Pernikahan : ..................................................................................
c. Pernikahan ke : ..................................................................................
d. Lama pernikahan : ..................................................................................
8. Riwayat Kontrasepsi yang digunakan
No Jenis Pertama Menggunakan Terakhir Menggunakan
Kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan

9. Pola Pemenuhan Kebutuhan Sehari-hari

a. Nutrisi
Sebelum Hamil
Makan : ..............................................................................................................
....
Minum :
...................................................................................................................
Keluhan :
...................................................................................................................
Selama Hamil
Makan :
...................................................................................................................
Minum :
...................................................................................................................
Keluhan :
...................................................................................................................
Pantangan :
...................................................................................................................

b. Pola Eliminasi
Sebelum Hamil

3|Dokumentasi
 BAB :
...................................................................................................................
BAK :
...................................................................................................................
Keluhan :
...................................................................................................................
Selama Hamil
BAB :
...................................................................................................................
BAK :
...................................................................................................................
Keluhan :
...................................................................................................................
c. Aktivitas sehari-hari
1). Pola istirahat dan tidur
Sebelum hamil :
………………………………………………………………….……
Keluhan :
.............................................................................................................
Selama hamil :
.............................................................................................................
Keluhan :
.............................................................................................................
2). Seksualitas
Sebelum hamil :
.............................................................................................................
Keluhan :
............................................................................................................
Selama hamil :
.............................................................................................................

Keluhan :
............................................................................................................

4|Dokumentasi
 3) Pekerjaan
Sebelum hamil :
.............................................................................................................
Selama hamil :
.............................................................................................................
Keluhan :
.............................................................................................................
4). Personal Hygiene
Sebelum hamil :
.............................................................................................................
Selama hamil :
.............................................................................................................
9. Riwayat Psikososial dan budaya
a. Apakah kehamilan ini direncanakan/ diinginkan :
...................................................................................................................
b. Kepercayaan yang berhubungan dengan kehamilan :
…………………………………………………………………………
c. Hubungan ibu dengan orang lain
…………………………………………………………………………
d. Pengambil keputusan :
…………………………………………………...
e. Rencana bersalin di :
……………………………………………...........
f. Jarak rumah dengan tempat bersalin
.......................................................
11. Pengetahuan Ibu tentang ANC ( Ante Natal Care )
a. Tablet Fe
...................................................................................................................
b. Gizi selama hamil
……………………………………………………………………….......
c. Perawatan Payudara
...................................................................................................................
b. Tanda- bahaya kehamilan

5|Dokumentasi
 ...................................................................................................................
c. Seksualitas dalam kehamilan
...................................................................................................................
12. Kebiasaan yang merugikan Ibu dan Janin
...................................................................................................................
C. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : …………………………
Kesadaran : …………………………
Status emosional : …………………………
b. BB sekarang : ………………………....
Sebelum hamil : ........................................
Kenaikan BB : ........................................
TB : ........................................
Lila : ........................................
c. Tanda-Tanda Vital
Tekanan darah : ........................................
Denyut nadi : ........................................
Pernafasan : ........................................
Suhu : …………………………
2. Pemeriksaan Fisik
a. Kepala dan Leher
Kepala : ………………………………………………………............
Muka : ..................................................................................
Alis mata : …………………………………………..................
Mata : …………………………………………………............
Konjungtiva : .....................................................................................
Sklera : .......................................................................................
Mulut dan Gigi
Mulut : ………………………………………………………............
Gusi : ………………………………………………………............
Gigi : ………………………………………………………............
Bibir : ………………………………………………………………

6|Dokumentasi
 Telinga : ………………………………………………………............
Hidung : ………………………………………………………………
Leher
Kelenjar Limfe : …………………………………………………...........
Kelenjar tyroid : …………………………………………………...........
Vena jugularis : ………………………………………………………...
b. Dada
Bentuk : ………………………………………………………...
Jantung : ………………………………………………………...
Paru-paru : .........................................................................................
c. Payudara
Putting susu : …………………………………………………….......
Bentuk : ………………………………………………………...
Benjolan : ………………………………………………………...
Rasa nyeri : .........................................................................................
d. Ketiak
Kelenjar limfe : …………………………………………...........
e. Abdomen
Bekas luka operasi : ………………………………………………...
Hepatomegali : .............................................................................
Splenomegali : .............................................................................
f. Pinggang dan punggung
Nyeri ketuk pinggang : .............................................................................
Posisi punggung : .............................................................................
g. Genetalia luar
Varises : ……………………………………………………...........
Luka parut : ……………………………………………..........
Oedema : ………………………………………………………...
Flour albus : ………………………………………………………...
h. Anus : …………………………………………………….......
i. Ekstremitas
Ekstremitas atas :
Telapak tangan : ………………………………………………………...

7|Dokumentasi
 Kuku : ………………………………………………………...
Kapiler refill : …………………………………………………...........
Oedema : …………………………………………………...........
Varises : .........................................................................................
Ekstremitas bawah
Telapak kaki : .........................................................................................
Kuku : .........................................................................................
Kapiler refill : .........................................................................................
Oedema : .........................................................................................
Varises : .........................................................................................
Refleks patella : .........................................................................................
3. Pemeriksaan obstetrik
a. Inspeksi
Payudara : …………………………………………………….......
Abdomen : …………………………………………………….......
Genetalia : .........................................................................................
b. Palpasi
Payudara : .........................................................................................
Abdomen : .........................................................................................
Leopold I :
...............................................................................................................................
Leopold II :
…………………………………………………………………………………..
Leopold III :
…………………………………………………………………………………..
Leopold IV :
…………………………………………………………………………………..
Palpasi luar : ..........................................................................................
Panjang uterus menurut Mc. Donald : ………………………..............................
TBJ : ………………………………………………….............

c. Auskultasi
DJJ : .........................................................................................

8|Dokumentasi
 d. Pemeriksaan Penunjang
...............................................................................................................................
II. ANALISA
1. Analisa:
………………………………………………………………………………….…..
……………………………………………………………………………….……..
…………………………………………………………………………….......................
................
Contoh:
Ny. ... umur ......... G... P... A... umur kehamilan .......................mgg,
janintunggal/ganda, hidup/mati intra uterin, letak memanjang/melintang...........,
punggung kanan / kiri......, presentasi kelapa/bokong.........., kelapa/bokong masuk
panggul / belum …………..
Data Dasar:
a. Subjektif: ...................................................................................................................
b. Objektif: ....................................................................................................................
2. Masalah
Data dasar :......................................................................................................................
3. Kebutuhan
Data dasar :......................................................................................................................
DIAGNOSA POTENSIAL
………………………………………………………………………………….
………………………………………………………………………….................................
...................
TINDAKAN SEGERA
……….……………………………………………………………………...…….……….
………………………………………………………………..............................................
PERENCANAAN TINDAKAN
………………….…………………………………………………………...
……………………….……………………………………………………...
……………….......................
III. PENATALAKSANAAN
Hari/ Tanggal :

9|Dokumentasi
Jam :
1. Pelaksanaan....................
Evaluasi...................................

Ttd

Bidan

10 | D o k u m e n t a s i
A.

CONTOH FORMAT ASUHAN IBU BERSALIN DG POLA PIKIR VARNEY

ASUHAN KEBIDANAN PADA IBU BERSALIN FISIOLOGIS
Ny...... Umur....th, G… P… A… UMUR KEHAMILAN………………………
Di..........................................................................

I. PENGKAJIAN
HARI/TANGGAL :………………………..
JAM :………………………..
No Register :………………………..

A. SUBYEKTIF
1. Identitas
KLIEN SUAMI
Nama Ibu :……………………………... ………………………….
Umur :…………………………….. ……………………….
Suku bangsa :………………………......... ......…………………….
Agama :…………………………….. ………………………….
Pendidikan :…………………………….. ........…………………….
Pekerjaan :…………………………….. …………………………….
Alamat :…………………………….. …………………………….
………………………........... …………………………….
2. Alasan datang
………………………………………………………………………………………
……………………………………………………………………….......................
3. Keluhan umum
………………………………………………………………………………………
……………………………………………………………………….......................
4. Riwayat menstruasi
Menarche Umur
:.......................................................................................................................

11 | D o k u m e n t a s i
 HPHT : ..............................................................................................
Siklus : ..............................................................................................
Lama : ..............................................................................................
Volume : .........................................................................................
Warna : .........................................................................................
Keluhan : .........................................................................................
5. Riwayat Kehamilan Sekarang
a. Frekuensi pemeriksaan :
b. Tempat Periksa :
c. Imunisasi TT :
d. Kenaikan BB :
e. Keluhan selama hamil :
f. Tabet fe :
6. Riwayat Kehamilan, Persalinan dan Nifas yang lalu
N Kehamilan Persalinan Nifas Ket (anak
o hidup/mati,
Jenis

Penolong

Jk

BB

PB

Masalah

Lochea

laktasi

Masalah
usia anak skrg

7. Riwayat Kesehatan
a. Dahulu :
……………………………………………………………………………………
…………………………………………………………………….......................
b. Sekarang :
……………………………………………………………………………………
……………………………………………………………………........................
c. Keluarga
................................................................................................................................
................................................................................................................................
d. Penyakit reproduksi (Obstetri Ginekologi)
................................................................................................................................
...............................................................................................................................
8. Riwayat Perkawinan
12 | D o k u m e n t a s i
 a. Usia menikah ………………………….......................................
b. Status Perkawinan : ………………………........................................
c. Pernikahan ke : ………………………......................................
d. Lama Pernikahan : ……………………….......................................

9. Riwayat Kontrasepsi yang Digunakan

N Jenis Pertama menggunakan Terakhir menggunakan
o kontrasepsi Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan

10. Pola Pemenuhan Kebutuhan Sehari- hari

a. Diet/makan
Selama hamil
Makan
……………………………………………………………………………………
…………………………………………………………………….......................
Minum
……………………………………………………………………………………
…………………………………………………………………….......................
Keluhan :……………………………………………………..........
Pantangan :……………………………………………………..........
Selama Bersalin
Makan Terakhir
……………………………………………………………………………………
…………………………………………………………………….......................
Minum terakhir
……………………………………………………………………………………
…………………………………………………………………….......................
b. Pola Eliminasi
Selama Hamil
BAB : …………………………………………………………
BAK : …………………………………………………………
Keluhan : …………………………………………………………
13 | D o k u m e n t a s i
 Selama Bersalin
BAB terakhir : ......................…………………………………………
BAK terakhir : …………………………………………………………
Keluhan : …………………………………………………………
c. Aktifitas Sehari- hari
1) Pola Istirahat dan Tidur
Selama Hamil
.......................………………………………………………………
Keluhan : …………………………………………………………..
Selama Bersalin
………………………………………………………………………
2) Seksualitas
Selama Hamil
………………………………………………………………………
Keluhan : …………………………………………………………
Selama Bersalin
………………………………………………………………………
3) Pekerjaan
Selama hamil
………………………………………………………………………
Selama bersalin
………………………………………………………………………
4) Personal Hygiene
Selama hamil
………………………………………………………………………
Selama bersalin
………………………………………………………………………
11. Riwayat psikososial dan budaya
a. Apakah persalinan ini direncanakan/diinginkan
……………………………………………………………………………

b. Kepercayaan yang berhubungan dengan persalinan

14 | D o k u m e n t a s i
 ……………………………………………………………………………
c. Kepercayaan yang berhubungan dengan religi
……………………………………………………………………………
d. Hubungan ibu dengan orang lain
……………………………………………………………………………
e. Persiapan persalinan yang telah dilakukan
……………………………………………………………………………
f. Tanggapan ibu dan keluarga terhadap proses persalinaan yang dihadapi
……………………………………………………………………………

12. Pengetahuan ibu tentang Persalinan

a. Cara mengejan yang baik
……………………………………………………………………………
b. Teknik Relaksasi
……………………………………………………………………………
c. Posisi Persalinan yang baik
……………………………………………………………………………

B. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : ………………………
Kesadaran : ………………………
Status emosional : ………………………
b. BB sekarang : ………………………
Sebelum hamil : ………………………
Kenaikan BB : ………………………
TB : ………………………
Tanda-Tanda Vital
Tekanan darah : ……………………………..mmHg
Denyut nadi : ................................................ x/mnt
Pernafasan : …………………………….. x/mnt
Suhu : …………………………….. ˚C

15 | D o k u m e n t a s i
2. Pemeriksaan Fisik
a. Kepala dan Leher
Kepala
...................................................................................................................
Muka : ...........................................................................................
Alis mata : ...........................................................................................
Mata
Konjungtiva : ...........................................................................................
Sklera : ..........................................................................................
Mulut dan Gigi
Mulut
...................................................................................................................
Gusi : .........................................................................................
Gigi : ........................................................................................
Bibir : .......................................................................................
Telinga : ......................................................................................
Hidung : .......................................................................................
Leher
Kelenjar Limfe : .............................................................................
Kelenjar tyroid :............................................................................
Vena jugularis :............................................................................
a. Dada
Bentuk........................................................................................................
Jantung : .............................................................................
Paru-paru : .............................................................................
b. Payudara
Putting susu : .............................................................................
Bentuk :............................................................................
Benjolan : ...........................................................................
Rasa nyeri : ...........................................................................
c. Ketiak
Kelenjar limfe : ...........................................................................

16 | D o k u m e n t a s i
 d. Puggung dan pinggang
Posisi tulang belakang : ...............................................................
Pinggang (nyeri ketuk) : ...............................................................
e. Abdomen
Bekas luka operasi : ...........................................................................
Hepatomegali : ...........................................................................
Splenomegali : ...........................................................................
f. Genetalia luar
Varises : ...........................................................................
Luka parut : ...........................................................................
Oedema : ...........................................................................
Flour albus : ...........................................................................
g. Anus
.................................................................................................................
h. Ekstremitas
Ekstremitas atas
Telapak tangan :..........................................................................
Kuku : ...........................................................................
Kapiler refill : ...........................................................................
Oedema : ...........................................................................
Varises :............................................................................
Ekstremitas bawah
Telapak kaki : ...........................................................................
Kuku : ............................................................................
Kapiler refill : ...........................................................................
Oedema : ...........................................................................
Varises : ...........................................................................
Refleks patella : ..........................................................................
Cianosis : ..........................................................................
4. Pemeriksaan obstetrik
a. Inspeksi
Payudara

17 | D o k u m e n t a s i
 ………………..…………………………………………………………
Abdomen
………………..…………………………………………………………
Genetalia
………………..…………………………………………………………
b. Palpasi
Payudara : ..………………………………………………
Palpasi Leopold
Leopold I :
…………………………………………………………………………………
…………..………………………………………………………………………
Leopold II :
…………………………………………………………………………………
…………..………………………………………………………………………
Leopold III :
…………………………………………………………………………………
…………..………………………………………………………………………
Leopold IV :
…………………………………………………………………………………
…………..………………………………………………………………………
Palpasi Luar
…………………………………………………………………………..............
His : Frekuensi : ………………...x dalam 10 menit
Durasi/lama : ……………….. detik
Kekuatan : ………………..
Panjang uterus menurut Mc. Donald : ………………………………
TBJ
…………………………………………………………………………
c. Auskultasi
DJJ…………………………………………………………………………
d. Pemeriksaan dalam
Atas Indikasi : …………………………………………………
Tanggal : ……………….

18 | D o k u m e n t a s i
 Jam : ……….
Oleh : .......................
Dinding Vagina
…………………………………………………………………………
Portio
…………………………………………………………………………
Pembukaan Servik
…………………………………………………………………………
Ketuban
…………………………………………………………………………
Tali Pusat
…………………………………………………………………………
Penurunan bagian terendah
…………………………………………………………………………
Posisi penunjuk (point of direction)
…………………………………………………………………………
Kesan Panggul/ukuran : …………………………………………
Imbang feto – pelvic : .......................................................................
5. Pemeriksaan Penunjang
………………………………………………………………………………………
…………………………………………………………………
II. ANALISA
………………………………………………………………………………………………
……………………………………………………………………………….......................
DIAGNOSA POTENSIAL
……………………………………………………………………………………………
…………………………………………………………………………….........................
TINDAKAN SEGERA
……………………………………………………………………………………………
……………………………………………………………………………........................

PERENCANAAN

19 | D o k u m e n t a s i
 ……………………………………………………………………………………………
……………………………………………………………………………........................
III. PELAKSANAAN
Hari/ tanggal :
Waktu :

……………………….,………………..20….
Mahasiswa

(………………………..)

20 | D o k u m e n t a s i
 CONTOH FORMAT ASUHAN BBL DG POLA PIKIR VARNEY
ASUHAN KEBIDANAN BAYI BARU LAHIR FISIOLOGIS
PADA By Ny. UMUR 0-2 jam
DI...............................................

I. PENGKAJIAN
HARI/TANGGAL :
JAM :

A. SUBJEKTIF
1. Identitas Bayi
Nama bayi :..................................
Tgl/jam/lahir : ..................................
Jenis Kelamin : ..................................

2. Identitas Orang Tua

Nama ibu : ............................. Nama Ayah : ............................
Umur : ............................. Umur : .............................
Suku/keb : ............................. Suku/ keb : .............................
Agama : ............................. Agama : .............................
Pendidikan :............................. Pendidikan : .............................
Pekerjaan : ............................ Pekerjaan : .............................
Alamat : ............................ Alamat : .............................

3. Riwayat Kehamilan
G…. P….. A…..
HPHT : ............................. HPL : .............................
NO Keterangan TM I TM II TM III
1 Tempat Periksa
2 Keluhan
3 Saran
4 Imunisasi TT
5 Kenaikan BB
6 Penkes
UK :.................................

21 | D o k u m e n t a s i
 4. Riwayat Persalinan Sekarang
Jenis persalinan :...............................................................................
Ditolong oleh :...............................................................................
Ketuban pecah :..............................................................................
Plasenta lahir secara :..............................................................................
Tali pusat :..............................................................................
Kala I
: ..........................................................................................................................
..........................................................................................................................
Kala II :
......................................................................................................................................
......................................................................................................................................
Kala III :
......................................................................................................................................
......................................................................................................................................
Kala IV :
......................................................................................................................................
......................................................................................................................................
5. Komplikasi / masalah Persalinan
......................................................................................................................................
......................................................................................................................................

B. DATA OBYEKTIF
Penilaian Awal
1. Warna kulit :............................................................................................
2. Pernafasan :...........................................................................................
3. Tonus otot :...........................................................................................

II. INTERPRETASI DATA

A. Diagnosa
............................................................................................................................................
...........................................................................................................................................
Data Dasar :

22 | D o k u m e n t a s i
 - Subjektif
.....................................................................................................................................
.....................................................................................................................................
- Objektif
.....................................................................................................................................
.....................................................................................................................................
B. Masalah
............................................................................................................................................
Data Dasar :
1. Subjektif
....................................................................................................................................
2. Objektif
.....................................................................................................................................
....................................................................................................................................
C. Kebutuhan
............................................................................................................................................
Data Dasar :
1. Subjektif
...................................................................................................................................
2. Objektif
...................................................................................................................................
III. DIAGNOSA POTENSIAL
.................................................................................................................................................
.................................................................................................................................................
IV. TINDAKAN SEGERA
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
V. PERENCANAAN
................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
................................................................................................................................................

23 | D o k u m e n t a s i
VI. PELAKSANAAN
Hari dan tanggal:
Jam:
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
...............................................................................................................................................
VII. EVALUASI
Hari dan tanggal:
Jam:
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

Mahasiswa

( )

24 | D o k u m e n t a s i
 CONTOH FORMAT ASUHAN IBU NIFAS DG POLA PIKIR VARNEY
ASUHAN KEBIDANAN PADA IBU NIFAS FISIOLOGIS
Ny...... Umur...... P...A..................Jam Post Partum/ Nifas hari ke -
Di..............................................

I. PENGKAJIAN
HARI/TANGGAL :
JAM :

SUBJEKTIF
1. IDENTITAS
Nama ibu :................................ Nama Suami :............................
Umur :................................ Umur :............................
Suku/Keb :................................ Suku/Keb :............................
Agama :................................ Agama :............................
Pendidikan :................................ Pendidikan :............................
Pekerjaan :................................ Pekerjaan :............................
Alamat :................................ Alamat :............................
................................. .............................
No. Register :
2. Keluhan Utama :
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................
3. Riwayat Kesehatan
a. Dahulu :
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
b. Sekarang :
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

25 | D o k u m e n t a s i
 c. Keluarga :
....................................................................................................................................
...................................................................................................................................
d. Obstetri Ginekologi :
....................................................................................................................................
....................................................................................................................................
4. Riwayat Menstruasi
Menarche Umur :........................................................................................
Siklus :........................................................................................
Lama :........................................................................................
Volume :........................................................................................
Warna
.........................................................................................................................................
.........................................................................................................................................
Konsistensi
.........................................................................................................................................
.........................................................................................................................................
Dismenorhea :.................................................................................................................
5. Riwayat Kehamilan dan Persalinan Sekarang
a. G P A
No. Keterangan TM I TM II TM III
1. Tempat periksa
2. Keluhan
3. Saran
4. Imunisasi TT
5. Kenaikan Berat Badan
6. Penkes

b. Riwayat Persalinan Sekarang

Kala I
.....................................................................................................................................
.....................................................................................................................................

Kala II

26 | D o k u m e n t a s i
 .....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
Kala III
.....................................................................................................................................
.....................................................................................................................................
Kala IV
.....................................................................................................................................
.....................................................................................................................................
6. Riwayat Kehamilan, Persalinan dan Nifas yang lalu
Hamil Persalinan Nifas
Tgl Umur Jenis Penolong Komplikasi Jenis BB Laktasi Komplikasi
Ke
lahir kehamilan persalinan kelamin lahir nifas

7. Riwayat Kontrasepsi yang Digunakan

N Jenis Pertama menggunakan Terakhir Menggunakan Rencana
Tanggal Oleh Tempat Keluhan Tanggal Oleh Tempat Alasan Jenis Alasan
o kontrsepsi

8. Riwayat Perkawinan
a. Usia waktu menikah :............................................................................
b. Pernikahan ke : ...........................................................................
c. Status pernikahan : ...........................................................................
d. Lama pernikahan : ...........................................................................

9. Pola Pemenuhan Kebutuhan Sehari- hari

a. Diet/makan

Selama Nifas
Makan Terakhir
......................................................................................................................................
......................................................................................................................................

27 | D o k u m e n t a s i
 Minum terakhir
......................................................................................................................................
......................................................................................................................................
Keluhan :....................................................................................................
Pantangan :....................................................................................................
Konsumsi Vitamin A : ………………………………………………………
Konsumsi Penambah Darah :………………………………………………..
b. Pola Eliminasi
Selama Nifas
BAB terakhir
......................................................................................................................................
......................................................................................................................................
BAK terakhir
......................................................................................................................................
......................................................................................................................................
Keluhan :.................................................................................................................

10. Aktifitas Sehari- hari

a. Pola Istirahat dan Tidur
Selama Nifas
..........................................................................................................................
Keluhan :....................................................................................................
b. Seksualitas
Selama Nifas
..........................................................................................................................
Keluhan :...................................................................................................
c. Personal hygiene
Selama nifas
..........................................................................................................................
d. Pekerjaan
Selama nifas
......................................................................................................................................
......................................................................................................................................

28 | D o k u m e n t a s i
 e. Pola Menyusui
1) Frekuensi menyusui ……………………………………………………..............
2) Lama waktu menyusui ………………………………………………….............
3) Menggunakan payudara kanan /kiri secara bergantian
…………………………………………………………………………
4) bayi di beri ASI saja atau dengan tambahan susu formula atau tambahan
makanan lainnya………………………………………………………….
5) Melakukan perawatan payudara / pijat oksitosin selama
nifas……………………………………………………………………
f. Pola Kebiasaan yang merugikan di masa nifas
......................................................................................................................................
......................................................................................................................................
11. Riwayat psikososial
a. Apakah kehamilan dan persalinan ini direncanakan/diinginkan?
..........................................................................................................................
b. Apakah ibu merasa senang dengan kehadiran bayinya?
..........................................................................................................................
c. Apakah ibu merasa sedih murung ataupun cemas dan ada perasaan bersalah?
............................................................................................................................
d. Apakah ibu memiliku kepercayaan yang berhubungan dengan nifas?
..........................................................................................................................
e. Bagaimana Hubungan ibu dengan orang lain?
..........................................................................................................................
12. Pengetahuan ibu tentang masa nifas
a. Nutrisi
......................................................................................................................................
...................................................................................................................................

b. Perawatan payudara
......................................................................................................................................
...................................................................................................................................
c. Tanda tanda bahaya masa nifas

29 | D o k u m e n t a s i
 ......................................................................................................................................
...................................................................................................................................
d. Seksualitas
......................................................................................................................................
....................................................................................................................................
e. Personal hygiene
......................................................................................................................................
......................................................................................................................................
f. Istirahat
......................................................................................................................................
......................................................................................................................................
g. Tablet Fe, Vitamin A
......................................................................................................................................
.....................................................................................................................................
DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan umum : ..............................
Kesadaran : ..............................
Status emosional :...............................
b. BB sekarang :...............................
Sebelum hamil :...............................
Kenaikan BB :...............................
TB :...............................
Lila :...............................
Tanda-Tanda Vital
Tekanan darah : .................. mmHg
Denyut nadi : .................. x/menit
Pernafasan : .................. x/menit
Suhu : .................. oC
2. Pemeriksaan Fisik
a. Kepala dan Leher
Kepala

30 | D o k u m e n t a s i
 ...............................................................................................................................
...............................................................................................................................
..............................................................................................................................
Muka : .........................................................................................
Alis mata : .........................................................................................
Mata
Konjungtiva : .........................................................................................
Sklera : .........................................................................................
Mulut dan Gigi
Mulut
...............................................................................................................................
...............................................................................................................................
Gusi : .........................................................................................
Gigi :..........................................................................................
Bibir : .....................................................................................................
...............................................................................................................................
..........................
Telinga
...............................................................................................................................
...............................................................................................................................
Hidung
...............................................................................................................................
...............................................................................................................................
Leher
Kelenjar Limfe : .............................................................................
Kelenjar tyroid :............................................................................
Vena jugularis :............................................................................

b. Dada
Bentuk

31 | D o k u m e n t a s i
 ...............................................................................................................................
..............................................................................................................................
Jantung : .............................................................................
Paru-paru : .............................................................................
c. Payudara
Putting susu
...................................................................................................................
Bentuk :............................................................................
Benjolan : ...........................................................................
Rasa nyeri : ...........................................................................
Striae : ...........................................................................
Lain-lain/bekas luka oprasi
..................................................................................................................
d. Ketiak
Kelenjar limfe : ...........................................................................
e. Puggung dan pinggang
Posisi tulang belakang : ...............................................................
Pinggang (nyeri ketuk) : ...............................................................
f. Abdomen
Bekas luka operasi : ...........................................................................
Hepatomegali : ...........................................................................
Splenomegali : ...........................................................................
g. Genetalia luar
Varises : ...........................................................................
Luka parut : ...........................................................................
Oedema : ...........................................................................
Flour albus : ...........................................................................
h. Anus
.................................................................................................................
i. Ekstremitas
Ekstremitas atas
Telapak tangan

32 | D o k u m e n t a s i
 ...............................................................................................................................
.......................................................................................................
Kuku : ...........................................................................
Kapiler refill : ............................................................................
Oedema : ...........................................................................
Varises :............................................................................
Ekstremitas bawah
Telapak kaki : ............................................................................
Kuku : ...........................................................................
Kapiler refill : ............................................................................
Oedema : ...........................................................................
Varises : ...........................................................................
Refleks patella : ..........................................................................
Homan Sign : ..........................................................................
Cianosis : ..........................................................................

6. Pemeriksaan obstetrik
a. Inspeksi
1) Payudara
...............................................................................................................................
...............................................................................................................................
2) Abdomen
...............................................................................................................................
..............................................................................................................................
3) Genetalia
..............................................................................................................................
..............................................................................................................................
b. Palpasi
1) Payudara
...............................................................................................................................
..............................................................................................................................

2) Abdomen :

33 | D o k u m e n t a s i
 TFU
............................................................................................................
Kontraksi
..............................................................................................................
DRA ………………………………………………………………..
3) Genetalia
...............................................................................................................................
...............................................................................................................................
7. Pemeriksaan Penunjang :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
II. ANALISA
Analisa
............................................................................................................................................
............................................................................................................................................
Data Dasar :
- Subjektif
.....................................................................................................................................
....................................................................................................................................
- Objektif
.....................................................................................................................................
.....................................................................................................................................
Masalah
............................................................................................................................................
Data Dasar :
1. Subjektif
.....................................................................................................................................
2. Objektif
.....................................................................................................................................
.....................................................................................................................................

D. Kebutuhan

34 | D o k u m e n t a s i
 ................................................................................................................................
Data Dasar :
1. Subjektif
.........................................................................................................................
2. Objektif
.........................................................................................................................
DIAGNOSA POTENSIAL
................................................................................................................................................
...............................................................................................................................................
ANTISIPASI TINDAKAN SEGERA
................................................................................................................................................
................................................................................................................................................
III. PENATALAKSANAAN
......................................, .............................20
Mahasiswa

(…………………………)

35 | D o k u m e n t a s i