YAYASAN MARANATHA

NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA
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ASUHAN KEBIDANAN PADA IBU NIFAS

P ….. A ….. AH ….. NIFAS HARI KE .......
DI ...........................................

Tanggal/Jam Pengkajian :
Nama Mahasiswa :
No.MR/Reg :

A. DATA SUBYEKTIF
1. Biodata
Nama ibu :.................. Nama suami :...................
Umur :.................. Umur :..................
Pendidikan :.................. Pendidikan :..................
Agama :.................. Agama :..................
Suku / bangsa :.................. Suku /bangsa :..................
Pekerjaan :.................. Pekerjaan :...................
Penghasilan :.................. Penghasilan :..................
Alamat :.................. Alamat :...................
2. Keluhan Utama:
.............................................................................................................
.............................................................................................................
3. Riwayat Perkawinan
a. Status perkawinan : .............................................................
b. Umur saat menikah : .............................................................
c. Lamanya menikah : .............................................................
d. Berapa kali kawin : ............................................................

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 4. Riwayat kehamilan, persalinan, dan nifas yang lalu
No Tgl/bln/ Jenis U Penolong temp keadaan BB/ J KET
thn pers K (Dokter/Bi at bayi saat PB K (saat
pers. dan) Lahir ini)
(LH /LM )

5. Riwayat persalinan sekarang :

a. Partus tanggal berapa :
 Kala I :..............................................................
 Kala II :..............................................................
 Kala III :..............................................................
 Kala IV :..............................................................
b. Obat-obatan
 Oksitosin : Lidocain :
c. Jenis persalinan :
d. Penolong :
6. Riwayat KB
 Cara kontrasepsi : ..............................................................
 Lamanya : ..............................................................
 Keluhan : ..............................................................
7. Latar belakang sosial budaya yang berkaitan dengan nifas
a. Makanan pantangan : .......................................................
b. Jenis makanan pantangan : ......................................................
c. Pantangan seksual : ......................................................
8. Dukungan keluarga:
9. Status gizi
 Pola makan : ..............................................................
 Nafsu makan : ..............................................................
 Jenis makanan : ..............................................................
 Jenis minuman : ..............................................................

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 10. Pola eliminasi
a. BAB b. BAK
 Warna : Warna :
 Bau : Bau :
 Frekuensi : Frekuensi :
 Keluhan : Keluhan :

11. Hubungan seksual :

...........................................................................................................
12. Dukungan psikologi :
...........................................................................................................................
...........................................................................................................................
13. Pola istirahat dan tidur
Saat nifas
 Tidur siang : .........................................
 Tidur malam :..........................................
 Kebisaan sebelum tidur :..........................................
 Kesulitan tidur :..........................................
14. Mobilisasi :
...........................................................................................................................
.....................................................................................................................
15. Perawatan diri
a. Perawatan payudara :....................................................
b. Vulva higiene :....................................................
c. Mandi :....................................................
d. Gosok gigi :....................................................
e. Cuci rambut :....................................................
f. Ganti pakaian dalam : ...................................................
g. Ganti pakaian luar :....................................................

B. DATA OBYEKTIF
1. Pemeriksaan umum
 Keadaan umum : …………………………………….
 Kesadaran :……………………………………..

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  Ekspresi wajah : …………………………………….
 Penanpilan : …………………………………….
 Tanda-tanda vital
Suhu : TD :
Nadi : Pernapasan :
2. Pemeriksaan fisik
a. Kepala : …………………………………………………...
b. Mata
 Conjungtiva : …………………………………………….
 Sclera :……………………………………………..
c. Mulut
 Mukosa bibir : …………………………………………….
 Gigi :……………………………………………..
 Lidah :……………………………………………..
d. Hidung :……………………………………………..
e. Tenggorokan
 Warna : ……………………………. ………
 Pembesaran tonsil :……………………………………..
f. Leher
 Pembesaran kelenjar tiroid : …………………….
 Pembendungan vena jugularis :……………………..
g. Dada
 Mamae : …………………………………….
 Putting susu :……………………………………..
 Areola mamae :……………………………………..
 Tanda-tanda infeksi :…………………………………….
 Laktasi : ……………………………………
h. Abdomen
 Dinding perut : ……………………………………
 Involusi :…………………………………….
 TFU : …………………………………….
 Kontraksi :……………………………………
 Vesika urinaria :…………………………………….
i. Vulva/vagina

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  Lochea : …………………………………….
 Warna : …………………………………….
 Banyaknya : …………………………………….
 Luka episiotomi : ……………………………………
 Tanda infeksi : …………………………………..
 Perlukaan yang bukan apisiotomi: ………………………..
j. Anus
 Haemoroid : …………………………………….
k.Ekstremitas atas/ bawah
 Refleks patella: …………………………………….
 Oedema:……………………………………………
 Varices:…………………………………………….
3. Pemeriksaan Penunjang
 Laboratorium
a. Urine
 Protein : ……………………………………
 Reduksi :……………….................................
b. Darah
 Hb : ……………………………...........
 Malaria :........................................................
 Dll........ :........................................................
 Radiologi
a. USG : …………………………………………….
b. Rontgen : …………………………………………….
4. Obat-obatan : …………………………………………….

C. ANALISA DATA
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D. PENATALAKSANAAN (Perencanaan, Pelaksanaan dan Evaluasi)
.......................................................................................................................................
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