PEMERINTAH KABUPATEN ENDE

DINAS KESEHATAN
PUSKESMAS ROGA
Jln. Demulaka - Roga email: pkmroga17@gmail.com

ASUHAN KEBIDANAN PADA IBU NIFAS

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

A. BIODATA

Nama Istri : .......................................... Nama Suami :.........................................................

Umur :...........................................
Agama :...........................................
Suku/Bangsa :...........................................
Pendidikan :...........................................
Pekerjaan :...........................................
Alamatkantor :...........................................
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 : .....................................................................................................
Menikahke : .....................................................................................................
Lamanya kawin : .....................................................................................................
Usiamenikahpertama 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. Dukungan Psikologis:

k. Pola Istirahat

Sebelum nifas Masa nifas

Tidur siang
Tidur malam
Kebiasaan sebelum tidur
Kesulitan tidur

l. Mobilisasi:

m. Personal Hygiene
Mandi : .............................................................
Gantipakaian : .............................................................
Gosokgigi : .............................................................
Keramas : .............................................................

C. DATA OBYEKTIF
1. Pemeriksaan Umum
Keadaan Umum : ........................................................
Kesadaran : ........................................................
 Bentuk Tubuh : ........................................................
Ekspresi Wajah : ........................................................
TandaVital Sign : ........................................................
TekananDarah : .............................. Nadi : ........................................
Pernafasan : .............................. Suhu : ........................................

2. PemeriksaanFisik
1) Kepala
a. Bentuk : ...................................................
b. Warna Kulit : ...................................................
c. NyeriTekan : ...................................................

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. KeadaanLidah : ...........................................................
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 :.................................................................
Laktasi :.................................................................

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. PemeriksaanPenunjang:
Urine :
Protein :
Reduksi :
HB :

4. Obat-obatan: