YAYASANRUSTIDA

AKADEMI KESEHATAN “RUSTIDA”

PROGRAM STUDI DIII KEBIDANAN
Jl. Bhakti Husada Krikilan – Glenmore – Banyuwangi
Telp 0333-821495 Fax-0333 821193

No. Target :
ASUHAN KEBIDANAN PADA IBU NIFAS
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I. LANGKAH I (PENGKAJIAN)
A. DATA SUBYEKTIF

(Tanggal pengkajian : ......................... Jam..................Wib)

1. BIODATA
Nama Ibu : ............................... Nama Suami : ...............................
Umur : ............................... Umur : ...............................
Pendidikan : ............................... Pendidikan : ...............................
Agama : ............................... Agama : ...............................
Suku/ Bangsa : ............................... Suku / Bangsa : ...............................
Pekerjaan : ............................... Pekerjaan : ...............................
Penghasilan : ............................... Penghasilan : ...............................
Alamat : ............................... Alamat : ...............................
No. Telp. : ...............................
No. Register : ...............................

2. Alasan kunjungan
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3. Keluhan utama
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4. Riwayat
menstruasi
a. Menarche umur :
 b. Siklus :
c. Volume :
d. Keluhan :
5. Riwayat pernikahan
a. Usia menikah pertama kali :
b. Status pernikahan :
c. Pernikahan ke :
d. Lama pernikahan :
6. Riwayat kesehatan yang lalu
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7. Riwayat kesehatan sekarang
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8. Riwayat kesehatan keluarga
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9. Riwayat kehamilan, persalinan, nifas yang lalu a) Kehamilan
a. Persalinan :
b. Nifas :
10. Riwayat kehamilan, persalinan dan nifas sekarang
a. Kehamilan
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b. Persalinan
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c. Nifas
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11. Riwayat KB dan Rencana KB :

12. Pola kebiasaan sehari-hari

a) Pola nutrisi
b) Pola eliminasi
c) Personal hygiene
d) Pola aktivitas
e) Pola istirahat/ tidur
13. Keadaan psikologi dan budaya

B. DATA OBYEKTIF
1. Pemeriksaan Umum
a. Keadaan umum :
b. Kesadaran :
c. Tanda vital
1) Tekanan darah :
2) Suhu :
3) Nadi :
4) RR :
d. Berat Badan :
2. Pemeriksaan fisik
a. Inspeksi
Wajah : ....................................................................................
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Mata : ....................................................................................

Leher : ....................................................................................
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Dada : ....................................................................................
 Perut : ....................................................................................
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Genetalia : ....................................................................................
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Ekstremitas :
Atas : ....................................................................................
Bawah : ....................................................................................

b. Palpasi
Leher : ....................................................................................
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Payudara : ....................................................................................
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Perut : ....................................................................................
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Ekstremitas :
Atas : ....................................................................................
Bawah : ....................................................................................
c. Auskultasi
Paru : ....................................................................................
d. Perkusi
Ekstremitas
Atas : ....................................................................................
Bawah : ....................................................................................
3. Data penunjang
Data bayi

a. Lahir tanggal : jam :

b. Keadaan umum :
c. Kesadaran : ................................................................................
d. Nadi : ................................................................................
e. RR : ................................................................................
f. BBL : ................................................................................
g. Jenis kelamin : ................................................................................
h. Nutrisi : ................................................................................
II. IDENTIFIKASI DIAGNOSA DAN MASALAH AKTUAL
a. Diagnosa kebidanan
“Ny “...” usia ...... P Ab Post Partum hari ke....dengan........................
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1. Data subyektif :
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2. Data objektif :
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b. Masalah
1. Data subyektif :
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2. Data obyektif :
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c. Kebutuhan
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III.IDENTIFIKASI DIAGNOSA DAN MASALAH POTENSIAL

a. Diagnosa potensial
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b. Masalah potensial
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IV. IDENTIFIKASI KEBUTUHAN SEGERA

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V. INTERVENSI
Tanggal/Pukul :

Tujuan :
Kriteria Hasil :
Rencana Tindakan (Intervensi)
No. Intervensi Rasional
VI. IMPLEMENTASI
Tanggal / Pukul :
TANGGAL/ JAM IMPLEMENTASI
II. LANGKAH VII (EVALUASI) (Tanggal : ................. Jam..............Wib)

S :

O :

A :

P :
 CATATAN PERKEMBANGAN

Tanggal....................................................................Jam.......................................................

DATA SUBJEKTIF (S)

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DATA OBYEKTIF (O)

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ASSESSMENT (A)

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PENATALAKSANAAN (P)

Tanggal ......................................................... Jam .............................................................

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Mahasiswa

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Pembimbing Klinik Pembimbing Institusi

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 LEMBAR PENGESAHAN

Asuhan kebidanan ini telah disetujui/disahkan pada

Hari :
Tanggal :

Pemberi Asuhan

( )

Mengetahui

Pembimbing Akademik Pembimbing Lapangan

( ) ( )

Menyetujui
Bidan Koordinator

( )
 LEMBAR KONSULTASI
Nama Mahasiswa :
Nim :
Judul Asuhan :
Hari/Tanggal Revisi Tanda Tangan

Pembimbing Klinik

( )
 SATUAN ACARA PENYULUHAN

Topik : ........................................................................
Sub Topik : ........................................................................
Sasaran : ........................................................................
Target : ........................................................................
Hari/ tanggal : ........................................................................
Waktu : ........................................................................
Tempat : ........................................................................
Penyuluh : ........................................................................

A. Latar Belakang

B. Tujuan intruksional umum (TIU)

C. Tujuan intruksional khusus (TIK)

D. Materi penyuluhan

E. Metode

F. Media

G. Evaluasi

H. Pengorganisasian dan urutan tugas

1. Pembawa acara
2. Notulen
3. Penyuluh
4. Fasilitator
5. Observer
I. Proses pelaksanaan
No Waktu Kegiatan penyuluhan Kegiatan peserta
1 Pembukaan
2 Pelaksanaan
3 Evaluasi
4 Terminasi

J. Evaluasi
1. Evaluasi struktur
2. Evaluasi proses
3. Evaluasi hasil

K. Referensi

L. Materi penyuluhan
Lampirkan materi peyuluhan yang diberikan

M. Lembar soal
Beri soal setelah kegiatan penyuluhan

N. Dokumentasi
Beri dokumentasi berupa foto kegiatan

...................,.............................20....
Penyuluh

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Mengetahui,
CI BPM/ PKM Pembimbing Akademik

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