PEMERINTAH KABUPATEN ENDE

DINAS KESEHATAN
PUSKESMAS KOTARATU
Jln. Kesehatan Telp. (0381) 2500760

ASUHAN KEBIDANAN PADA IBU NIFAS

PENGKAJIAN
Tanggal Pengkajian : ..........................................................................................................................
Oleh Bidan : ..........................................................................................................................

A. BIODATA

Nama istri : .......................................... Nama Suami :.........................................................

Umur :...........................................
Agama :...........................................
Suku/Bangsa :...........................................
Pendidikan :...........................................
Pekerjaan :...........................................
Alamat kantor :...........................................
Alamat rumah :...........................................
No. Telp/HP : ..........................................
Umur :.........................................................
Agama :.........................................................
Suku/Bangsa :.........................................................
Pendidikan :.........................................................
Pekerjaan :.........................................................
Alamat kantor :.........................................................
Alamat rumah :.........................................................
No. Telp/HP :.........................................................

B. DATA SUBYEKTIF

a. Keluhan Utama:
............................................................................................................................................. .....
........................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................

b. Riwayat Perkawinan
Status pernikahan : .....................................................................................................
Menikah ke : .....................................................................................................
Lamanya kawin : .....................................................................................................
Usia menikah pertama kali : .....................................................................................................
 c. Riwayat kehamilan, persalinan dan nifas yang lalu:

Tanggal Keadaan
No UK Penolong Tempat Penyulit JK BB/PB Ket.
Persalinan bayi
1.

2.

3.

4.

5.

6.

d. Riwayat Persalinan:
Tanggal Persalinan: ......................................... Jam ........................................
Kala I : ................ jam
Kala II : ................ jam
Kala III : ................ jam
Kala IV : ................ jam
Obat-obatan : ...............................................
Oxytocin : ...............................................
Lidocain : ...............................................
Jenis Persalinan: ...............................................

e. Riwayat Keluarga Berencana:

 KB yang pernah digunakan : ...........................................................

 Lamanya : ...........................................................
 Efek samping : ...........................................................
 Alasan berhenti : ...........................................................

f. Latar belakang sosial budaya yang berkaitan dengan nifas:

 Pantangan makanan : .................................................
 Pantangan seksual : .................................................
 Dukungan keluarga : .................................................

g. Status Gizi
 Pola makan : ...................................................
 Nafsu makan : ...................................................
 Jenis makanan : ...................................................
 Minuman : ...................................................
 h. Pola Eliminasi
- BAB
Frekuensi : .............................................................
Konsistensi : .............................................................
Warna : .............................................................
Bau : .............................................................
Keluhan : .............................................................
- BAK
Frekuensi : .............................................................
Konsistensi : .............................................................
Warna : .............................................................
Bau : .............................................................
Keluhan : .............................................................

i. Hubungan seksual:

J. Dukunagn psikologis:

k. Pola Istirahat

Sebelum nifas Masa nifas

Tidur siang
Tidur malam
Kebiasaan sebelum tidur
Kesulitan tidur

l. Mobilisasi:

m. Personal hygiene
Mandi : .............................................................
Ganti pakaian : .............................................................
Gosok gigi : .............................................................
Keramas : .............................................................

C. DATA OBYEKTIF
1. Pemeriksaan Umum
Keadaan Umum : ........................................................
Kesadaran : ........................................................
Bentuk tubuh : ........................................................
Ekspresi wajah : ........................................................
Tanda vital Sign : ........................................................
Tekanan Darah : .............................. Nadi : ........................................
Pernafasan : .............................. Suhu : ........................................
2. Pemeriksaan Fisik
1) Kepala
a. Bentuk : ...................................................
b. Warna kulit : ..................................................
c. Nyeri tekan : ..................................................

2) Rambut
a. Bentuk : ...............................................
b. Bau rambut : ..............................................
c. Warna rambut : ...............................................

3) Muka
a. Bentuk : ...................................................
b. Oedem : ...................................................
c. Cloasma gravidarum : ...................................................

4) Mata
a. Kesimetrisan : ...........................................................
b. Konjungtiva : ...........................................................
c. Sklera :

5) Hidung
a. Kesimetrisan :
b. Polip :
c. Infeksi :
d. Serumen :

6) Mulut
a. Kesimetrisan : ...........................................................
b. Keadaan bibir : ...........................................................
c. Keadaan gigi : ...........................................................
d. Keadaan gusi : ...........................................................
e. Keadaan Lidah : ...........................................................
f. Kelenjar Tonsil : ...........................................................

7) Telinga
a. Kesimetrisan : ...........................................................
b. Lubang Telinga : ...........................................................
c. Gendang Telinga : ...........................................................
 d. Pendengaran : ...........................................................
e. Serumen : ...........................................................

8) Leher
a. Tidak ada Pembesaran kelenjar tiroid
b. Tidak ada Pembesaran kelenjar limfe
c. Tidak ada Pembesaran kelenjar parotis
d. Tidak ada Pembesaran vena jugularis

9) Dada
Mammae :.................................................................
Areola mammae :.................................................................
Puting susu :.................................................................
Tanda2 infeksi :.................................................................
Lactasi :.................................................................

10) Perut
Strie :.................................................................
Dinding perut :.................................................................
Involusi :.................................................................
Kontraksi uterus :.................................................................
TFU :.................................................................
Vesika urinaria :.................................................................

11) Genetalia
Vulva/vagina :.......................................
Lochea :.......................................
Warna :.......................................
Banyaknya :.......................................
Bau :.......................................
Luka perineum :.......................................
Luka episiotomie :.......................................
Tanda infeksi :.......................................
Perlukaan yang bukan episiotomie :.......................................

12) Anus
Haemoroid

13) Tungkai
Refleks patela
 Oedema
Varices

3. Pemeriksaan Penunjang:
Urine
Protein
Reduksi
HB

4. Obat-obatan: