LAPORAN

ASUHAN KEBIDANAN PADA IBU NIFAS NORMAL

PADA NY……………..USIA….TH….NIFAS HARI/MINGGU KE….
DI……………………………………………………..

A. PENGKAJIAN

Tanggal : …………………….................

Waktu : …………………….................

Tempat : …………………….................

Biodata :

1. Nama ibu :................................. 1. Nama suami :…………………………

2. Umur :................................. 2. Umur :…………………………

3. Suku bangsa :................................. 3. Suku bangsa :…………..……………..

4. Agama :................................ 4. Agama :…………………..……..

5. Pendidikan :................................ 5. Pendidikan :…………………………

6. Pekerjaan :................................ 6. Pekerjaan :…………………………

7. Alamat :................................ 7. Alamat: :………………………….

B. DATA SUBYEKTIF

1. ALASAN DATANG:
…………………...................................................................................................................................................
.........…………………..........................................................................................................
2. KELUHAN UTAMA:
……………..........................................................................................................................................................
..............................................................................................................................................
Uraian Keluhan
Utama .....................................................................................................................................................
…………………................................................................................................................
 3. Riwayat obstetri:
a. Riwayat Haid:
Menarche : …………......................... Nyeri Haid : …………................
Siklus : …………......................... Lama : …………................
Warna darah : …………......................... Leukhorea : …………................
Banyaknya : ………………….......................................................................................
b. Riwayat Persalinan dan Nifas yang lalu
Persalinan Nifas
Kead anak
Tahun Asi
UK Jenis Penolong JK/ BB Penyulit IMD Penyulit sekarang
eksklusif

c. Riwayat persalinan Sekarang

Paritas : ..….. Abortus : ………

Tempat persalinan :………………………………… Ditolong oleh :………………….

Jenis persalinan :………………………………….

Masalah dalam persalinan :………………………………….

Keadaan Plasenta :………………………………….

Kedaan tali pusat :………………………………….

Keadaan bayi :…………………………………. Jenis kelamin………………….

Tanggal/ jam lahir :…………………………………. Apgar score…………………….

BB :…………………...gr, PB :……...cm LK:……...cm, LD:……...cm

Kelainan bawaan :………………………………….

d. Riwayat Kesehatan :
Penyakit/kondisi yang pernah atau sedang
diderita : ..................................................................................................
…………………...................................................................................................................................................
...........
…………………...................................................................................................................................................
............................................................................................................................................................................
.
Riwayat penyakit dalam Keluarga (menular maupun keturunan)
: ...............................................................................
…………………...................................................................................................................................................
...........
…………………...................................................................................................................................................
............................................................................................................................................................................
....................
e. Riwayat KB : Pernah/Tidak pernah *)

Lama
Jenis KB Keluhan Alasan Berhenti
Penggunaan

Rencana KB : ……………………………………………………..
f. Pola Pemenuhan Kebutuhan Sehari-Hari:
1) Nutrisi
a) Makan
 Frekuensi makan pokok : ……….. x perhari
 Komposisi :
 Nasi : ……. x @ ……. piring (sedang / penuh)
 Lauk : …….. x @ ……. potong (sedang / besar), jenisnya…………................
 Sayuran : …….. x @ ……… mangkuk sayur ; jenis sayuran.................................
 Buah : …….. x sehari / seminggu; jenis ………………………………….............
 Camilan : ……… x sehari; jenis ……………………………………….......................
  Pantangan : ………………………… alasan…………………..........................
b) Minum
 Jumlah total ……….. .gelas perhari; jenis…………………………................
 Susu ……….. ………..gelas perhari; jenis susu…………………………........
2) Eliminasi
a) Buang Air Kecil :
 Frekuensi perhari : …………. x ; warna…………………….............................
 Keluhan/masalah : ……………………………………………………….............................
b) Buang Air Besar :
 Frekuensi perhari : ……x ; warna ………………… konsistensi lembek / keras*)
 Keluhan/masalah : ……………………………………………………….............................
3) Personal hygiene
 Mandi ……… x sehari
 Keramas ……. x seminggu
 Gosok gigi …….. x sehari
 Ganti pakaian ……….. x sehari; celana dalam ……….. x sehari
 Kebiasaan memakai alas kaki : ………………………………...............................................
4) Hubungan seksual
 Frekuensi : …….. x seminggu
 Keluhan lain : ……………………………..…........................................................................
5) Istirahat/tidur
 Tidur malam ………….. jam
 Tidur siang ……………. jam
 Keluhan/masalah : …………………………………………….................................................
6) Aktivitas fisik dan olah raga
 Aktivitas fisik (beban pekerjaan) ……………………………………...........................
 Olah raga : jenisnya ……………………………………..…….. frekuensi ……. x seminggu
……………………………………..…….. frekuensi ……. x seminggu
7) Kebiasaan yang merugikan kesehatan :
 Merokok : ................................................................................................
 Minuman beralkohol : .................................................................................................
 Obat-obatan : ................................................................................................
 Jamu : ................................................................................................
8) Pola menyusui : ...............................................................................................................
9) Riwayat Psikososial-spiritual
a) Riwayat perkawinan :
 Status perkawinan : menikah / tidak menikah*), umur waktu menikah : .................th.
 Pernikahan ini yang ke ………… sah/ tidak*) lamanya ………..................................th
 Hubungan dengan suami : baik/ ada masalah
b) Kehamilan ini diharapkan / tidak*) oleh ibu, suami, keluarga;
Respon & dukungan keluarga terhadap nifas ini....................................................
c) Mekanisme koping (cara pemecahan masalah) : ……………………....................................
d) Ibu tinggal serumah dengan : ..……………………………………….......................................
e) Pengambil keputusan utama dalam keluarga : ......……………..…......................................
f) Dalam kondisi emergensi, ibu dapat / tidak * mengambil keputusan sendiri.
g) Orang terdekat ibu : ...……................................................…………………………...............
h) Yang menemani ibu untuk kunjungan PNC : ...……………………...……………..................
i) Adat istiadat yang dilakukan ibu berkaitan dengan Nifas : ………………….........................
j) Penghasilan perbulan: Rp..................................……….......…….........Cukup/Tidak Cukup*)
k) Praktk agama yang berhubungan dengan nifas : ...............................................................
l) Keyakinan ibu tentang pelayanan kesehatan : ....................................................................
 ibu dapat menerima segala bentuk pelayanan kesehatan yang diberikan oleh nakes wanita
maupun pria;
 tidak boleh menerima transfusi darah;
 tidak boleh diperiksa daerah genitalia,
 lainnya : ..................................................................................
m) Tingkat Pengetahuan Ibu :
Hal-hal yang sudah diketahui ibu : .......................................................................................
Hal-hal yang belum diketahui ibu : .......................................................................................
.................................................................................................................................
.................................................................................................................................
Hal-hal yang ingin diketahui ibu : .......................................................................................
.................................................................................................................................
.................................................................................................................................
C. DATA OBYEKTIF

1. PEMERIKSAAN FISIK:
a. Pemeriksaan Umum:
1) Keadaan umum : ...........
2) Kesadaran : ...........
3) Tensi : ...........
4) Suhu /T : ...........
5) Nadi : ...........
6) RR : ...........
b. Status present
Kepala :................................................................................................................
Muka :................................................................................................................
Mata :................................................................................................................
Hidung :................................................................................................................
Mulut :................................................................................................................
Telinga :................................................................................................................
Leher :................................................................................................................
Ketiak :................................................................................................................
Dada :................................................................................................................
Abdomen :................................................................................................................
Lipat paha :................................................................................................................
Vulva :................................................................................................................
Ekstremitas :................................................................................................................
Punggung :................................................................................................................
Anus :................................................................................................................
c. Status Obstetrik
Muka : ...............................................................................................................
Mamae : ...............................................................................................................
Abdomen : ...............................................................................................................
Genetalia : Lokea. ............................................................
Luka perenium:.... ..........................................
 2. Pemeriksaan
penunjang : ...............................................................................................................................................
...............................................................................................................................................
D. ANALISA

...................................................................................................................................................................................
...................................................................................................................................................................................
...............................................................................................
E. PELAKSANAAN Tanggal ............................................. Jam ..................

1. ......................................................................................................................................................
Hasil : ............................................................................................................................................
2......................................................................................................................................................
Hasil :
...............................................................................................................................................
3 .......................................................................................................................................................
Hasil : .
......................................................................................................................................................
4. ......................................................................................................................................................
Hasil :
....................................................................................................................................................
5. ......................................................................................................................................................
Hasil : ..
...................................................................................................................................................
........................, .......................2017
Pembimbing Klinik Praktikan

------------------------------ -------------------------------------
Mengetahui
Pembimbing Institusi

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 Catatan Perkembangan

RB/BPM NO.RM
Nama Pasien:
Nama Bidan:
CATATAN PERKEMBANGAN

Tanggal dan CATATAN PERKEMBANGAN Nama dan

Jam Paraf
(SOAP)
S=

O=

A=

P=