Lampiran 14

YAYASAN RUMAH SAKIT ISLAM NUSA TENGGARA BARAT

SEKOLAH TINGGI ILMU KESEHATAN YARSI MATARAM
PROGRAM STUDI D.III KEBIDANAN
Jl. TGH. Ali Batu Lingkar Selatan Mataram, Telp/Fax. 0370 6161271, 6161261

FORMAT PENGKAJIAN
ASUHAN KEBIDANAN PADA IBU POST PARTUM / NIFAS

Tanggal pengkajian : ......................

Jam :.......................
No rekam medik : ......................
Tempat pengkajian : ......................

LANGKAH I : PENGKAJIAN
DATA SUBYEKTIF
A. Identitas
Identitas klien
Nama pasien : ............................. Nama suami : ........................
Umur : ............................. Umur : ........................
Agama : ............................. Agama : ........................
Suku/bangsa : ............................. Suku /bangsa : .......................
Pendidikan : ............................. Pendidikan : ........................
Pekerjaan : ............................. Pekerjaan : ........................
Alamat : ............................. Alamat : ........................
B. Keluhan utama / alasan kunjungan
......................................................................................................................................
Riwayat kesehatan sekarang
......................................................................................................................................
......................................................................................................................................
C. Riwayat kesehatan yang dahulu
......................................................................................................................................
......................................................................................................................................
D. Riwayat kesehatan keluarga
......................................................................................................................................
......................................................................................................................................
E. Riwayat menstruasi
Menarche :.................................. disminorhe : .........................
Siklus : ................................. flour albus : ..........................
Lama : .................................
F. Status perkawinan
Berapa kali menikah : ................................................................................
Umur pertama kali menikah
Suami : ............................................ Istri : …………………………………….
Lama : ........................................................................................................

G. Riwayat obstetri

Perka Keha Penyulit

U Tempa Usia
winan milan JP Penolong BB JK Ket
K t anak
no no Keha Persali
Nifas
milan nan

Jenis KB : ............................. Kapan berhenti : ...............................

 Lama : ............................. alasan berhenti : ..............................
Mulai KB : .............................
H. Keadaan psikologi
......................................................................................................................................
......................................................................................................................................
I. Pola kebiasaan sehari-hari
a. Nutrisi
Makan : ...........................frekuensi ........................./hari,
Komposisi :............................porsi.....................................................................
Minum : .......................... per hari, jenis …………………………………...
b. Eliminasi
BAK : ..................x/hari, keluhan ……………………………………….
BAB : ..................x/hari, keluhan ……………………………………….
c. Istirahat/ tidur : ............................................................................................
d. Aktifitas sehari-hari : ............................................................................................
e. Personal higiene : .............................................................................................
J. Riwayat sosial ekonomi
......................................................................................................................................
......................................................................................................................................
K. Riwayat sosial budaya
......................................................................................................................................
......................................................................................................................................
DATA OBYEKTIF
L. Pemeriksaan umum
Keadaan umum : ..........................................................................................................
Kesadaran :..........................................................................................................
Tekanan darah : ............................mmHg
Pernafasan : ............................kali/menit
Suhu : ...........................0C
Berat badan : ........................... kg
Tinggi badan : ...........................cm
M.Pemeriksaan fisik
Kepala : ............................................................................................
Muka : …………………………………………………………….
Mata : .............................................................................................
Telinga : .............................................................................................
Hidung : .............................................................................................
Mulut : .............................................................................................
Leher : .............................................................................................
Payudara : .............................................................................................
Abdomen : .............................................................................................
Ekstermitas atas : ............................................................................................
Ekstermitas bawah : ............................................................................................
Genitalia : ............................................................................................
Lain-lain jelaskan : .............................................................................................
N. Pemeriksaan penunjang
Lain-lain jelaskan : .............................................................................................

LANGKAH II : INTERPRETASI DATA DASAR DAN INDENTIFIKASI

DIAGNOSIS/MASALAH
Diagnosa / masalah :
DS : ..........................................................................................................................
DO : ..........................................................................................................................

LANGKAH III : IDENTIFIKASI DIAGNOSA / MASALAH POTENSIAL

Diagnosa / masalah potensial :
LANGKAH IV : IDENTIFIKASI KEBUTUHAN SEGERA
Mandiri :
Kolaborasi :
Rujukan :

LANGKAH V : RENCANA ASUHAN MENYELURUH

Rencana asuhan :

LANGKAH VI : PELAKSANAAN
Tanggal :
Jam :
Implementasi :

LANGKAH VII: EVALUASI

Tanggal :
Jam :
Evaluasi :
(bila dilakukan perawatan, menggunakan catatan perkembangan)

CATATAN PERKEMBANGAN
CATATAN PERKEMBANGAN
NO HARI/TANGGAL CATATAN PERKEMBANNGAN
S :
O:
A:
P :