POLITEKNIK KESEHATAN KEMENKES BANDUNG

JURUSAN KEPERAWATAN BANDUNG

FORMAT DOKUMENTASI ASKEP POST PARTUM/NIFAS &

BAYI BARU LAHIR NORMAL

Judul Askep : ..............................................................................................................

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

I. PENGKAJIAN

A. Identitas Klien

IDENTITAS ISTRI SUAMI

Nama
Umur
Suku bangsa
Agama
Pendidikan
Pekerjaan
No. register
Tanggal masuk RS
Hari / Tanggal pengkajian
Waktu / jam pengkajian
Golongan darah
Diagnosa medis

Nomor telepon
Status perkawinan
Alamat rumah

Alamat kantor

B. Riwayat Kesehatan

1. Keluhan utama (here and now) :

2. Riwayat kesehatan sekarang:

alinea 1 (kronologis dari awal keluhan sampai sebelum anda kaji termasuk keluhan pada saat
masuk RS/Puskesmas) :

alinea 2 (PQRST dari keluhan utama):

3. Riwayat kesehatan dahulu:

4. Riwayat kesehatan keluarga (fokus pada penyakit genetik & menular):

5. Riwayat kesehatan ginekologi dan obstetri.
a. Riwayat ginekologi
1) Riwayat menstruasi / haid
- Menarche : ............................................................
- Siklus haid : ............................................................
- Keluhan selama haid : ............................................................
2) Riwayat perkawinan
Status pernikahan : ............................................................

ISTRI SUAMI
Umur waktu menikah
Lama pernikahan
Pernikahan yang ke

3) Riwayat Keluarga Berencana (KB)

- Jenis kontrasepsi yang digunakan : ................................................
- Lamanya : ................................................
- Alasan dilepas : ................................................
- Dukungan keluarga : ................................................
- Rencana kontrasepsi sesudah melahirkan : ................................................

b. Riwayat Obstetri
1) Riwayat kehamilan, persalinan dan nifas yang lalu

Kehamilan Persalinan Nifas

Ta Umur ANC Pe Jenis Tempat/ Peny L/P, Lak Penyulit
No hun (kali)/ nyulit penolong ulit H/M, tasi
tempat BB

2) Riwayat kehamilan sekarang

- P: ........, A: .............
- HPHT : ...............................................
- Taksiran persalinan : ...............................................
- Tanggal persalinan : ...............................................
- Siklus haid : ...............................................
- Tanda bahaya atau penyulit : ...............................................
- ANC di: ................................ Frekuensi : ...............................................
- Obat yang dikonsumsi (termasuk jamu) : ...............................................
- Imunisasi TT 1: .................... TT2 : ...............................................
- Kekhawatiran khusus : ................................................
- Respon ibu dan keluarga terhadap kelahiran : ................................................
- Komplikasi kehamilan: - Perdarahan : ................................................
- Preeklampsia : ................................................
- Eklampsia : ................................................
- PMS : ................................................
 - Lain-lain sebutkan : ................................................

3) Riwayat persalinan
- Jenis persalinan: - Spontan: ..............., Buatan VE/FE/SC :............, Anjuran: ..................
- Masa gestasi: ......................................, Penolong persalinan: ..........................................
- Lama persalinan: Kala I: ............., Kala II: .............., Kala III:............., Kala IV: ................
- Keadaan ketuban: Warna: .........................., Jumlah: ........................................
- Keadaan plasenta: Berat: ..................., Diameter: ....................., Cotyledon: ....................
- Komplikasi persalinan: ................................., Trauma persalinan: ....................................

C. Pola Aktivitas Sehari-hari

Jenis Sebelum Sekarang
Makan
- Frekuensi ...................................... ...........................................
- Jenis ...................................... ...........................................
- Porsi ...................................... ...........................................
- Keluhan ...................................... ..........................................
- Makanan yang dipantang, alasan ...................................... ..........................................
- Alergi ..................................... ..........................................
- Suplemen ...................................... ..........................................
Minum
- Jenis ...................................... ..........................................
- Jumlah ...................................... ..........................................
Eliminasi
- BAB: frekuensi, warna, konsistensi ..........., ..........., ............ .............., ..............., ............
- BAK: Frekuensi, warna, bau ..........., ........., .............. .............., ..............., ............
Istirahat dan Tidur
- Malam ...................................... .............................................
- Siang ...................................... .............................................
- Keluhan ...................................... .............................................
- Yang mempermudah tidur ...................................... .............................................
- Yang mempermudah bangun ...................................... .............................................

Personal hygiene
- Mandi ...................................... .............................................
- Ganti pakaian dalam ...................................... .............................................
- Jenis pakaian ...................................... .............................................
- Perawatan gigi ...................................... .............................................
- Perawatan payudara ...................................... .............................................
- Vulva hygiene ..................................... .............................................
.
Pola aktivitas / kebiasaan hidup
- Pengetahuan hub sek pasca melahirkan ...................................... .............................................
- Keluhan ...................................... .............................................
- Kebiasaan merokok ...................................... .............................................
- Beban pekerjaan ...................................... .............................................
- Adat istiadat ...................................... .............................................
- Minum beralkohol ...................................... .............................................

D. Pemeriksaan Fisik

1. Ibu

1. Keadaan Umum
 Kesadaran: Compos Mentis (conscious) ........ Apatis..........Delirium..........Somnolen (Obtundasi,
Letargi)..........Stupor (Soporo koma) .........Coma (Comatode).............
2. Tanda-tanda vital
TD: ...................mmHg N: ..............x/mnt R: .............x/mnt S: ................. oC

3. Antropometri
TB: ...........cm BB sekarang: .............Kg BB sebelum hamil: ...............Kg IMT: ................(..............)

4 Kepala
Rambut: ................................................................, - Cloasma gravidarum: ......................................
Mata: - Penglihatan : ......................................... - Konjunctiva: ............................................
- Kelopak mata : ......................................... - Sclera : ...........................................
- Gerakan bola mata: .............................., - Reaksi pupil terhadap cahaya:............................
Telinga: - Kebersihan: .......................................... - Fungsi pendengaran: ........................................
Hidung: - Kebersihan: .......................................... – Funsi penciuman: .............................................
Mulut: - Bibir: ................................- Gusi: ..................................- Gigi caries: ..................................
- Gigi berlubang: ................- Gigi ompong: .....................- Gigi palsu: ..................................
Leher: - Pembesaran kelenjar tiroid: ................ .- Pembesaran kelenjar getah bening: ..................
5 Dada: - Pergerakan nafas: .................................... - Bunyi nafas: ..................................................
- Bunyi jantung: ........................................... - Irama Jantung: ..............................................
Payudara:
Indikator Kanan Kiri
Bentuk
Puting susu
Areola
Benjolan
Kolostrum
Kebersihan

6 Perut: - Luka bekas operasi/luka perineum: .................. - Panjang: ...............cm

- Keadaan luka : ...................................................- Luka parut: .........................................
- Striae: ................................................................- Penurunan TFU: .................................
- Posisi uterus: .................................................... – Kontraksi uterus: ................................
- Diastasis rektus abdominis: .............................................................................................
- REEDA (redness, edema, ecchymosis, drainage, approximation): ..................................
7 Ekstremitas

Indikator Kanan Kiri

Ekstremitas atas
Bentuk ............................................... ...............................................
Odema ............................................... ...............................................
Kuku jari ............................................... ...............................................
Ektremitas bawah
Bentuk ............................................... ...............................................
Odema ............................................... ...............................................
Kuku jari ............................................... ...............................................
 Varices ............................................... ...............................................
Refleks patela ............................................... ...............................................
Hommans sign ............................................... ...............................................
8 Genetalia
- Vulva/Vagina: .................................................................................................................................
- Lochea (jenis, bau, warna, jumlah): ...............................................................................................
- Perineum: ......................................................................................................................................
- Anus: .............................................................................................................................................
9 Data Psikologis
- Status emosi: ..............................................................................................................................
- Pola Koping: ...............................................................................................................................
- Pola Komunikasi: ........................................................................................................................
- Konsep diri: - Gambaran diri: .....................................................................................................
- Peran diri: ...........................................................................................................
- Ideal diri: .............................................................................................................
- Identitas diri: .......................................................................................................
- Harga diri: ...........................................................................................................
10 Data Sosial
Dengan keluarga dan tetangga: ..........................................................................................................
.............................................................................................................................................................
Dengan tenaga kesehtan: ...................................................................................................................
.............................................................................................................................................................
Dengan sesama pasien: .....................................................................................................................
.............................................................................................................................................................
11 Data Spiritual
- Keyakinan dan makna hidup: .......................................................................................................
- Autoritas dan pembimbing: ..........................................................................................................
- Pengalaman dan emosi: ..............................................................................................................
- Persahabatan dan Komunitas: .....................................................................................................
- Ritual dan Ibadah: ........................................................................................................................
- Dorongan dan pertumbuhan: .......................................................................................................

12 Data Penunjang

13 Data Therapi

2. Data Bayi

1. Identitas Bayi
 - Nama bayi: .....................................................................................................................
- Jenis kelamin: ................................................................................................................
- Tanggal Lahir / Jam Lahir: .............................................................................................
- No Registrasi: ................................................................................................................
- Berat Badan (BB)/Panjang Badab (PB): ........................................................................
- Hari/tanggal pengkajian: ................................................................................................
2. APGAR SKORE

Kriteria 1 menit 5 menit

Appearance (colour = warna kulit)
Pulse (heart rate = denyut nadi)
Grimace (refleks terhadap rangsangan)
Activity (tonus otot)
Respiration (usaha bernafas)
Jumlah

3. Pemeriksaan Fisik
Kesadaran: Menangis / Tidur nyenyak / Tidur dengan gerakan mata yang tepat (REM, rapid eye
movement) / Aktif – Sadar / Tenang – Sadar / Transisional
Tanda-tanda vital
- Suhu: ............0C Nadi: .............x/mnt Pernafasan: ...........x/mnt Tekanan Darah: ..........mmHg
Karakteristik Khusus Neonatus
- Kepala....................................................dari panjang tubuh keseluruhan
- Lingkar kepala: .....................cm, Molding:......................, Fontanel anterior: .....................cm
Fontanel posterior: .....................cm.
- Kulit: ......................, Vernik kaseosa: ............................, Milia:.................Lanugo: ..................
Eritema toksikum: ...................., Bercak mongolia: .................,Tanda lahir (Nevi): ....................
Ikterik: ...............
- Rambut: ...................., bulu mata: ................................, Alis: ....................................................
- Kuku jari: .........................................................................

4. Payudara
- Bayi laki-laki: .........................................................................................
- Bayi perempuan: ...................................................................................

5. Genetalia
- Bayi laki-laki: .............................................................................................................................
- Bayi perempuan: .......................................................................................................................

6. Reflek normal pada bayi lahir

Refleks pelindung: Refleks makan:

- Moro: ......................................................
- Tonus leher: ...........................................
- Menggengam: ........................................
- Mata berkedip: .......................................
- Menangis: ..............................................
- Menghisap: ...............................................
- Rooting: ....................................................
- Menelan: ...................................................
- Gag: ..........................................................

Refleks bernafas Indera Khusus:

- Gerakan pernafasan: ...............................
- Bersin: ......................................................
- Batuk: .........................................................
- Sentuhan, rasa sakit, tekanan: .................
- Penciuman: ...............................................
- Pengecapan: .............................................
- Pendengaran: ...........................................
- Penglihatan: .............................................

II. DIAGNOSA KEPERAWATAN

 A. Analisa Data

No. Data Kemungkinan penyebab Masalah

1 DS:

DO:

2. DS:

DO:

3 DS:

DO:

B. Diagnosa Kkeperawatan Berdasarkan Prioritas::

1.
2.
3.

III. PERENCANAAN
Perencanaan
No. Diagnosa Keperawatan
Tujuan Intervensi Rasional
1.
 2.

3.

IV. PELAKSANAAN

Diagnosa
No. Tanggal/jam Tindakan Keperawatan Paraf
Keperawatan
V. EVALUASI

Diagnosa
Tanggal/jam Evaluasi Paraf
Keperawatan

S:

O:

A:

P:

I :
E:

R:

S:

O:

A:

P:

I :

E:

R:

S:

O:

A:

P:

I :

E:

R: