ASUHAN KEBIDANAN IBU NIFAS

1. PENGKAJIAN
1.1 DATA SUBJEKTIF
Anamnesa dilakukan oleh :...............................................Di....................................
Pada tanggal.................................................. pukul.......................................................
1.1.1 IDENTITAS KLIEN No. Register : ...........................
Nama Klien :...................................... Nama Suami : ...........................
Umur : ...................................... Umur : ...........................
Suku/ Bangsa : ...................................... Suku/ Bangsa : ...........................
Agama : ...................................... Agama : ...........................
Pendidikan : ...................................... Pendidikan : ...........................
Pekerjaan : ...................................... Pekerjaan : ...........................
Penghasilan : ...................................... Penghasilan : ...........................
Alamat : ...................................... Alamat : ...........................

1.1.2 Keluhan utama

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1.1.3 Riwayat menstruasi
 Menarche : .......................................................................................
 Siklus menstruasi : ......................(teratur/tidak teratur)
 Lama : .......................................................................................
 Banyaknya darah : .......................................................................................
 Konsistensi : .......................................................................................
 Dysmenorhoe : Ya/tidak (sebelum/selama/sesudah menstruasi)
 Flour albus : Ya/tidak (sebelum/selama/sesudah menstruasi)
Warna:..........Bau:........... Gatal:.............
 HPHT : .......................................................................................
 Taksiran persalinan:.......................................................................................

1.1.4 Status perkawinan

 Kawin :........ Kali..............
 Lama kawin :.................................. tahun

1.1.5 Riwayat kehamilan, persalinan, dan nifas yang lalu

Kehamilan Persalinan Nifas Anak
Suami
No. Umur penyul penol jenis temp penyul penyul L/ BB/PB menyusui H/M KB Ket
ke
P
1.1.6 Riwayat kehamilan sekarang
- Hamil yang ke..............................dengan umur kehamilan.........................
- Gerakan anak dirasakan pertama kali sejak umur kehamilan......................
gerak anak sekarang...................
- Selama hamil, memeriksakan kehamilannya di....................berapa kali.........
Imunisasi TT dimana...................berapa kali...................kapan......................
- Keluhan yang dirasakan selama hamil ini
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1.1.7 Riwayat persalinan sekarang

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1.1.8 Riwayat kesehatan keluarga

a. Keturunan kembar : ...........................................................................
Dari pihak siapa : ...........................................................................
b. Penyakit keturunan : ...........................................................................
Jenis penyakit : ...........................................................................
Dari pihak siapa : ...........................................................................
c. Penyakit lain dalam keluarga : ..............................................................
Jenis penyakit : ..............................................................
Dari pihak siapa : ..............................................................

1.1.9 Riwayat kesehatan yang lalu

 Penyakit menahun : ...........................................................................
 Penyakit menurun : ...........................................................................
 Penyakit menular : ...........................................................................

1.1.10 Latar belakang budaya dan dukungan keluarga

- Kebiasaan/upacara adat istiadat saat hamil : ................................................
- Pantangan saat sesudah melahirkan/ masa menyusui: .................................
- Kebiasaan keluarga yang menghambat : ................................................
- Kebiasaan keluarga yang menunjang : ................................................
- Dukungan dari suami : ................................................
- Dukungan dari keluarga yang lain : ................................................
 1.1.11 Pola kebiasaan sehari-hari
a. Pola Nutrisi
Selama hamil...................................................................................................
Sesudah melahirkan........................................................................................
Masalah yang dirasakan : ...........................................................................
b. Pola Eliminasi
Selama hamil...................................................................................................
Sesudah melahirkan........................................................................................
Masalah yang dirasakan : ...........................................................................
c. Pola istirahat tidur
Selama hamil...................................................................................................
Sesudah melahirkan........................................................................................
Masalah yang dirasakan : ...........................................................................
d. Pola Aktivitas
Selama hamil...................................................................................................
Sesudah melahirkan........................................................................................
Masalah yang dirasakan : ...........................................................................
e. Perilaku Kesehatan
Penggunaan obat/jamu/rokok, dll selama hamil: ............................................
Penggunaan obat/jamu/rokok, dll sesudah melahirkan: .................................

1.1.12 Sistem Psikososial

a. Fase taking in
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b. Fase taking hold
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c. Fase letting go
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d. Fase post partum blues
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1.2 DATA OBJEKTIF

1.2.1 Riwayat persalinan sekarang
Kala I
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Kala II
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 Kala III
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Kala IV
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1.2.2 Pemeriksaan Umum
 Kesadaran : ...................................................
 Tekanan Darah : ...................................................
 Suhu : ...................................................
 Nadi : ...................................................
 RR : ...................................................
 BB (sebelum hamil) ...................................................sekarang: ..................
 TB : ...................................................

1.2.3 Pemeriksaan Khusus

a. Inspeksi
 Kepala : ..................................................
 Muka : Kelopak mata : ..................................................
Conjungtiva : ..................................................
Sklera : ..................................................
 Mulut dan gigi : Bibir : ..................................................
Lidah : ..................................................
Gigi : ..................................................
 Hidung : Simetris : ..................................................
Sekret : ..................................................
Kebersihan : ..................................................
 Leher : Pembesaran vena jugularis : ..........................
Pembesaran kelenjar thyroid: ..........................
Pembesaran kelenjar getah bening : ..........................
 Dada : Simetris : ..........................
Pembesaran payudara : ..........................
Hiperpigmentasi : ..........................
Papila mammae : ..........................
Keluaran : ..........................
Kebersihan : ..........................
 Perut : Pembesaran : ..........................
Bekas luka operasi : ..........................
Linea : ..........................
Striae : ..........................
Pembesaran lien/ liver : ..........................
 Anogenetalia : Vulva vagina warna : ..........................
Luka parut : ..........................
Oedema : ..........................
Varises : ..........................
Keluaran : ..........................
Hemorroid : ..........................
Kebersihan : ..........................
 Ekstremitas atas dan bawah : Oedema : ..........................
Varises : ..........................
 Kekakuan sendi: ......................
b. Palpasi
 Leher : Pembesaran vena jugularis : ..........................
Pembesaran kelenjar thyroid: ..........................
Pembesaran kelenjar getah bening : ..............
Struma : ..........................
 Dada : Benjolan/ Tumor : ..........................
Keluaran : ..........................
 Perut : Pembesaran lien/ liver : ..........................
TFU : ..........................
Kontraksi uterus : ..........................
Kandung kemih : ..........................
 Ekstremitas atas dan bawah : Oedema : ........................

1.2.4 Pemeriksaan penunjang

Laboratorium :.....................................................................................................
Foto : ....................................................................................................
Lain-lain : ....................................................................................................

2. DIAGNOSA
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3. RENCANA
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4. PELAKSANAAN (Tanggal....................................... Jam.................................)

Tanggal/jam Kegiatan/Monitoring

5. EVALUASI (Tanggal....................................... Jam.................................)

Subyektif Obyektif Assesment Planning