Format Asuhan Kebidanan Pada Ibu Nifas
Format Asuhan Kebidanan Pada Ibu Nifas
I. PENGKAJIAN
Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
Cara masuk :
Diagnose :
A. DATA SUBYEKTIF
1. Keluhan
utama : ....................................................................................................................................
.................................................................................................................................................
...........
2. Riwayat menstruasi
Usia manarche :
Jumlah darah haid :
HPHT :
Keluhan saat haid :
Lama haid :
Flour albus :
TP :
Keluhan haid :
Dll..............
No. Tgl, Th Tempat Umur Jenis Penolong Penyulit Anak Keadaan anak
partus partus kehamilan Kelamin persalinan JK/BB sekarang
4. Riwayat kesehatan penyakit yang pernah diderita :
Anemia
Hipertensi
Kardiovaskular
TBC
Diabetes
Malaria
IMS (Sphilis, GO, HIV/AIDS, dll)
Lain-lain....
Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................
Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
Lain-lain
5. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
................................................................................................................................................
B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla :
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang : nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang melebur
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
b. TFU : .............................., Kontraksi Uterus : Baik/lembek
Diastesis rectus abdomonis : +/-, ............................
Kandung kemih : Kosong/ penuh
Vulva Vagina : Lochea.................., Bau +/-
Luka Jalan lahir : Ruptur/Episiotomi, bengkak/tidak, bersih/kotor, luka
jahitan bertaut/tidak, basah/kering
Tanda-tanda Reeda (Red, Echimosis, Edema, Discharge, Aproximal)
Ekstremitas : Tromboflebitis (ada/tidak, berapa lama....................)
4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- CTG : janin................reaktif/tidak
- USG : ...........................................
- Foto thorak : ............................................
- EKG : ............................................
D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Kediri,............................
.................................................... ......................................................
NIP. NIM.
Dosen Pembimbing
....................................................
NIP.