ASUHAN KEBIDANAN POST PARTUM PADA NY ’’M’’

POST PARTUM HARI I DENGAN ASI KURANG

DI RSUD dr PALEMMAI TANDI
TANGGAL 05 MARET 2023

No Register :xxxxxxx
Tgl Partus : 04 Maret 2023 Pukul: 08.18 wita
Tgl Pengkajian : 05 Maret 2023 Pukul: 10.00 wita
Nama pengkaji : Naharia

LANGKAH I: IDENTIFIKASI DATA DASAR

Identitas Istri/Suami
Nama : Ny “M” / Tn “A”
Umur : 31 tahun/ 32 tahun
Nikah : 7 tahun
Suku : Bugis/Bugis
Agama : Islam / Islam
Pendidikan : SMA/SMA
Pekerjaan : IRT/Wiraswasta
Alamat : Jl.KMH.Razak
A. Keluhan Utama

B. Riwayat kehamilan, persalinan, dan nifas

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C. Riwayat kesehatan/ penyakit yang lalu dan sekarang
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D. Riwayat reproduksi
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E. Riwayat keluarga berencana
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F. Pola Kebiasaan Sehari-hari
1. Nutrisi
Selama Hamil:
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Selama Nifas:
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2. Personal Hygiene
Selama Hamil:
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Selama Nifas:
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3. Eliminasi
Selama Hamil:
BAK :....................................................................................................................
BAB :....................................................................................................................
Selama Nifas:
BAK :....................................................................................................................
BAB :....................................................................................................................
4. Istirahat
Selama Hamil:
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Selama Nifas:
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5. Keadaan Pskologis
Selama Hamil:
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Selama Nifas:
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6. Spiritual
 Selama Hamil:
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Selama Nifas:
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G. Riwayat psikososial, ekonomi, dan spiritual
1. ...................................................................................................................
2. ...................................................................................................................
3. ...................................................................................................................
4. ...................................................................................................................
5. ...................................................................................................................
H. Pemeriksaan fisik
1. Pemeriksaan Umum
a. Keadaan umum :
b. Kesadaran:
2. Pemeriksaan tanda-tanda vital
a. Tekanan darah :
b. Suhu :
c. Nadi :
d. Pernapasan :
3. Pemeriksaan head to toe
a. Mata :
b. Mulut/gigi:
c. Leher :
d. Payudara :
e. Abdomen :
f. Genitalia :
g. Ekstremitas :

LANGKAH II: IDENTIFIKASI DIAGNOSA/ MASALAH AKTUAL

Masalah Aktual : ...............................................
1................................................
DS :.........................................................................................................................
DO :.........................................................................................................................
 Analisa dan interpretasi data:
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DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
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LANGKAH III: IDENTIFIKASI DIAGNOSA/ MASALAH POTENSIAL

Masalah Potensial : ...............................................
1................................................
DS :.........................................................................................................................
DO :.........................................................................................................................
Analisa dan interpretasi data:
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LANGKAH IV: IDENTIFIKASI PERLUNYA TINDAKAN SEGERA DAN

KOLABORASI
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LANGKAH V: RENCANA ASUHAN

1. Tujuan Asuhan:
a.....................................................................................................................
b. ...................................................................................................................
c.....................................................................................................................
2. Kriteria :
a.....................................................................................................................
b. ...................................................................................................................
c.....................................................................................................................
3. Rencana Asuhan
Tanggal ............................... Pukul: ....................................
a.....................................................................................................................
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Rasional : ..........................................................................................................
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b. ...................................................................................................................
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Rasional : ..........................................................................................................
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c.....................................................................................................................
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Rasional : ..........................................................................................................
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d. ...................................................................................................................
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Rasional : ..........................................................................................................
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e.....................................................................................................................
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Rasional : ..........................................................................................................
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f. ....................................................................................................................
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Rasional : ..........................................................................................................
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g. ...................................................................................................................
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Rasional : ..........................................................................................................
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 LANGKAH VI: IMPLEMENTASI
Tanggal: ....................................... Pukul:..................................
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10. ........................................................................................................................
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LANGKAH VII: EVALUASI

Tanggal: ....................................... Pukul:..................................
1...........................................................................................................................
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2...........................................................................................................................
3...........................................................................................................................
4...........................................................................................................................