KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN KEMENKES MALANG

JURUSAN KEBIDANAN
PROGRAM STUDI SARJANA TERAPAN KEBIDANAN KEDIRI
Jl. KH. Wakhid Hasyim No. 64 B Telp. (0354) 773095 – 772833
Website : http://www.poltekkes-malang.ac.id Fax. (0354) 778340
Email : direktorat@poltekkes-malang.ac.id Kediri 64114

FORMAT ASUHAN KEBIDANAN PADA IBU NIFAS (PNC)

I. Pengkajian
Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Alamat : Alamat :

Cara Masuk :
Datang sendiri Rujukan dari :
Diagnosa MRS :

A. DATA SUBJEKTIF
1. Keluhan utama : ................................................................................................................
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2. Kronologi MRS : (Sebelum dirujuk/datang ke RS (IGD) hingga sampai ke ruangan

(Bersalin/ Nifas/ Bayi))
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3. Riwayat menstruasi
 Usia manarche :
 Jumlah darah haid :
 HPHT :
 Keluhan saat haid :
 Lama haid :
 Flour albus :
 TP :
 Keluhan haid :
Dismenorhoe Spoting Menorrhagia
Premenstrual syndrome Dll..........

3. Riwayat kehamilan, persalinan, dan nifas yang lalu.

G ................. P ................ A ............. Hidup ..................

Tgl,th Jenis Keadaan

Tempat Umur Penolong Anak
No partu persalina Penyulit anak
partus kehamilan persalinan JK/BB
s n sekarang

4. Riwayat kesehatan penyakit yang pernah diderita :

 Anemia
 Hipertensi
 Kardiovaskular
 TBC
 Diabetes
 Malaria
 IMS (Sphilis, GO, dll)
 Lain-lain....
Pernah dirawat : ya/tidak Kapan : ........................... Dimana :.................
Pernah dioperasi : ya/tidak Kapan : ........................... Dimana :.................
5. Riwayat penyakit keluarga (Ayah, Ibu, Mertua) yang pernah menderita sakit :
.............................................................................................................................................

6. Status pernikahan : ya/tidak

Nikah.............kali, nikah usia..............tahun, lama menikah....................tahun

7. Riwayat psiko sosial ekonomi

- Respon ibu dan keluarga terhadap kehamilan
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- Penggunaan alat kontrasepsi KB
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- Dukungan keluarga
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- Pengambilan keputusan dalam keluarga
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- Gizi yang dikonsumsi dan kebiasaan makan
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- Kebiasaan hidup sehat
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- Beban kerja sehari
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- Tempat dan penolong persalinan yang diinginkan
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- Penghasilan keluarga
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8. Riwayat KB dan rencana KB

Metode yang pernah dipakai: .......................................
Lama : ...................bulan/tahun
Komplikasi dari KB : ...................................
Rencana KB selanjutnya : ....................

9. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS
Endometriosis Polip serviks Kanker kandungan
Opersai kandungan Perkosaan DUB
dll
 10. Pola makan / minum/ eliminasi/ istirahat
- Pola minum : .................gelas/hari alkohol Jamu
Kopi
- Pola eliminasi :
BAK.................cc/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK
terakhir jam :.........
BAB..................kali/hari, karakteristik: lembek/keras, BAB terakhir
jam :.........................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................
- Dukungan keluarga : Suami Orang tua
Mertua Keluarga lain

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
- 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 : ............................................

C. ANALISIS/INTERPRETASI DATA
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D. PENATALAKSANAAN
Tanggal : ........................ Jam : .................................
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Kediri,............................

Pembimbing Praktik Mahasiswa

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NIP. NIM.

Dosen Pembimbing

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NIP.