ASUHAN KEBIDANAN PADA IBU NIFAS

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Tempat Praktik
No RM
Datang Tanggal

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Nama Mahasiswa
NIM
Keterampilan ke

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SUBJEKTIF
PENGKAJIAN DATA , Tanggal :
Jam :
1. Identitas
Ibu
Suami
Biodata
: ....................................................... .......................................................
Nama
: ....................................................... .......................................................
Umur
: ....................................................... .......................................................
Agama
Suku/Bangsa : ....................................................... .......................................................
: ....................................................... .......................................................
Pendidikan
: ....................................................... .......................................................
Pekerjaan
: .......................................................
Alamat
2. Kunjungan saat ini
A. Kunjungan Pertama
B. Kunjungan Ulang
Keluhan utama/alasan kunjungan saat ini :
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
3. Riwayat Perkawinan
Kawin..... kali. Kawin pertama umur ...... tahun. Dengan suami sekarang..............bulan/tahun
4. Riwayat Menstruasi
Menarche umur
Teratur/tidak, lama
Disminorea
HPMT

:
tahun
:
hari.
: ya/tidak.
:

Siklus
Flour Albus
Sifat Darah
HPL

:
hari
: ada/tidak
: Encer/ Beku
:

5. Riwayat Kehamilan, persalina dan nifas lalu

Hamil
ke

Persalinan
Tgl
lahir

Umur
kehamilan

Jenis
Persalinan

Penolong

Nifas
Komplikasi
Ibu
Bayi

Jenis
kelamin

BB
Lahir

Laktasi Komplikasi

6. Riwayat Kontrasepsi
No

Jenis
Kontrasepsi

Tanggal

Mulai memakai
Oleh
tempat

Keluhan

Tanggal

Berhenti/Ganti Cara
Oleh
Tempat

Alasan

7. Riwayat Kesehatan
a. Penyakit sistemik yang pernah/sedang diderita (Hipertensi, TBC, Asma, Diabetes
Melitus, Jantung,Ginjal, HIV/AIDS)
.............................................................................................................................................
.............................................................................................................................................
b. Penyakit yang pernah/sedang diderita keluarga (Hipertensi, TBC, Asma, Diabetes
Melitus, Jantung,Ginjal, HIV/AIDS)
.............................................................................................................................................
.............................................................................................................................................
8. Riwayat Kehamilan dan Persalinan Terakhir
Masa gestasi
:
Tempat persalinan:
Penolong :
Jenis persalinan : spontan/tindakan
Atas indikasi :
Komplikasi
:
Perineum
: utuh/ruptur (derajat 1/2/3/totalis)
Episiotomi (medialis/lateralis/mediolateral)
Tidak dijahit/ dijahit/ tanpa anestesia
Perdarahan
: Kala I
a. Pola Nutrisi Makan
Minum
Frekuensi
.................................................
.................................................
Macam
.................................................
.................................................
Jumlah
.................................................
.................................................
Keluhan
.................................................
.................................................
b. Pola Eliminasi BAB
BAK
Frekuensi
................................................. .................................................
Warna
................................................. .................................................
Bau
................................................. .................................................
Konsistensi
................................................. .................................................
Jumlah
................................................. .................................................
c. Pola aktivitas
Kegiatan sehari-hari : .................................................................................................
Istirahat/Tidur
: .................................................................................................
Seksualitas
: Frekuensi ....................
Keluhan..............................................
d. Personal Hygiene
Kebiasaan mandi ........ kali/hari
Kebiasaan membersihkan alat kelamin.....................................
Kebiasaan mengganti pakaian dalam........................................
Jenis pakaian dalam yang digunakan.......................
e. Imunisasi
TT 1 Tanggal ................................ TT 4 Tanggal ................................
TT 2 Tanggal ................................ TT 5 Tanggal ................................
TT 3 Tanggal ................................
9. Riwayat Kehamilan, Persalinan dan nifas yang lalu
Ibu dengan G....P....Ab....Ah.....
10. Riwayat Kontrasepsi
c. Riwayat keturunan kembar/cacat
.............................................................................................................................................

d. Riwayat Alergi
Makanan : ........................................................................................................................
Obat
: ........................................................................................................................
Zat lain : ........................................................................................................................
e. Kebiasaan-kebiasaan
Merokok : ...............................................................................................................

Minum jamu-jamuan : .......................................................................................................

Minum-minuman keras : ..................................................................................................
Makanan/minuman pantang : ...........................................................................................
Perubahan pola makan : ...................................................................................................
11. Riwayat Psiko Sosial Spiritual
a. Kehamilan ini
A. Dinginkan
B.Tidak diinginkan
b. Pengetahuan ibu tentang kehamillan
.........................................................................................................................................
.........................................................................................................................................
c. Pengetahuan ibu tentang kondisi/keadaan yang dialami sekarang
.........................................................................................................................................
.........................................................................................................................................
d. Penerimaan ibu terhadap kehamilan saat ini
.........................................................................................................................................
.........................................................................................................................................
e. Tanggapan keluarga terhadap kehamilan
.........................................................................................................................................
.........................................................................................................................................
f. Persiapan/rencana persalinan
.........................................................................................................................................
.........................................................................................................................................

OBJEKTIF Tanggal :

Jam :

1. Pemeriksaan Fisik
a. Keadaan umum...................................
Kesadaran......................................
b. Tanda Vital
Tekanan darah
: ...........mmHg
Nadi
: ...........kali per menit
Pernafasan : ...........kali per menit
Suhu
: ...........C
c. TB
: ...........cm
BB
: sebelum hamil .......kg, BB sekarang ....... kg
IMT
: ...........
LLA
: ...........cm
d. Kepala dan leher
Oedem Wajah
: .......................................................................................
Chloasma gravidarum: ada/tidak
Mata
: .......................................................................................
Mulut
: .......................................................................................
Leher
: .......................................................................................
e. Payudara
Bentuk
: .......................................................................................
Areola mammae
: .......................................................................................
Puting susu
: .......................................................................................
Colostrum
: .......................................................................................
f. Abdomen
Bentuk
: .......................................................................................
Bekas luka
: ada/ tidak ada
Striae gravidarum : ada / tidak ada

g. Palpasi Leopold
Leopold I

: Pada fundus teraba..................................................................

Leopold II

: Perut sebelah kiri teraba ........................................................

Perut sebelah kanan teraba.....................................................

Leopold III

: Pada SBR teraba.....................................................................

Leopold IV
Osborn Test
TFU (Mac Donald)
TBJ
Auskultasi DJJ

: .................................................................................................
:.........................................................................................
:.........cm
: (......-........)x155 = ............gram
: Punctum maximum .......................................................
Frekuensi.x/menit

h. Ekstremitas
Oedem
Varices
Reflek Patela
Kuku
i. Genetalia Luar
Tanda Chadwick
Varices
Bekas luka
j. Anus
Hemoroid

: ada/tidak ada
: ada/tidak ada
: kaki kanan.kaki kiri ..
:........................................................................................
: ada/tidak ada
: ada/tidak ada
: ada/tidak ada

Kelenjar Bartholini
Pengeluaran

: ada/tidak ada
: ada/tidak ada

: ada/tidak ada

2. Pemeriksaan panggul luar

Distansia spinarum
: ............cm
Distansia cristarum
:.............cm
Boudelouqe
: ............cm
Lingkar panggul
: ............cm

(normal)
(23-26cm)
(26-29cm)
(18-20cm)
(80-90cm)

3. Pemeriksaan Penunjang
....................................................................................................................................................
....................................................................................................................................................

ANALISA, Tanggal :

PENATALAKSANAAN, Tanggal :

Jam :

Jam :