ASUHAN KEBIDANAN
PADA Ny…. P……. NIFAS NORMAL
DI……….
I.
SUBYEKTIF
Pada tanggal :……………… oleh : …………….. pukul : …………………
1. Identitas
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Nama Ibu
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
No. register
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:
:
:
:
:
:
:
:
:
:
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Nama Suami
Umur
Suku/bangsa
Agama
Pendidikan
Pekerjaan
Penghasilan
Alamat
No. telp.
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:
:
:
:
:
:
:
:
:
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2. Keluhan
Utama (PQRST) :
...........................................................................................................................................
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3. Riwayat obstetri yang lalu
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No
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Kehamilan
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Persalinan
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BBL
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Nifas
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||||||||
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UK
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Peny.
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Jenis
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Pnlg.
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Tmp
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Peny
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JK
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PB/BB
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Hdp/Mt
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Usia
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Kead.
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Lak.
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4.
Pola Kesehatan Fungsional
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Pola Fungsi Kesehatan
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Selama hamil
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Setelah bersalin
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1.Pola
Nutrisi
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2.Pola
Eliminasi
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3.Pola
Istirahat
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4.Pola
Aktivitas
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5.Pola
seksual
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6. Pola persepsi dan
pemeliharaan kesehatan : merokok, alcohol, narkoba, obat – obatan,
jamu, binatang peliharaan
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5. Riwayat penyakit sistemik
yang pernah di derita :
|
1.
Jantung
2.
Ginjal
3.
Asma
4.
TBC
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6. Riwayat kesehatan dan
penyakit keluarga
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1.
Jantung
2.
Ginjal
3.
Asma
4.
TBC
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5.
Hepatitis
6.
DM
7.
Hipertensi
8.
TORCH
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9.
Gemeli
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7. Riwayat psikososiospiritual
·
Riwayat emosional :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
·
Status perkawinan
Kawin : …….. kali
Suami ke :
……
Kawin I :
Umur …………… tahun
Lamanya …………. tahun
Kawin ke II : umur …………… tahun
Lamanya…….......... tahun
·
Kehamilan ini
Direncanakan Tidak direncanakan
·
Hubungan dengan keluarga
Akrab biasa
terganggu
·
Hubungan dengan orang lain
Akrab biasa
terganggu
·
Ibadah / spiritual
Patuh tidak
patuh
·
Respon ibu dan keluarga terhadap bayinya :
.........................................................................................................................................
.........................................................................................................................................
·
Dukungan keluarga :
.........................................................................................................................................
·
Pengambil keputusan dalam keluarga :
..... ...................................................................................................................................
·
Tradisi :
..... ...................................................................................................................................
·
Riwayat KB :
..... ...................................................................................................................................
..... ...................................................................................................................................
..... ...................................................................................................................................
II. OBYEKTIF
1. Riwayat persalinan :
IBU :
Kala I : ………..jam………….menit
Kala II : ………..jam
………….menit
Dipimpin meneran
:………..jam ………….menit
Komplikasi : Kala I
:......................./ Kala II:.........................
Air ketuban : banyak
:..............cc, warna :................................Jam :..............
Kala III : ………………jam
…………..menit
Komplikasi :…………………………………………………………………
Plasenta :
-
Maternal :
Lengkap Tidak
lengkap
Maternal :
Lengkap Tidak
lengkap
-
Fetal : Lengkap Tidak lengkap
Fetal : Lengkap Tidak lengkap
-
Berat : ……………..gr
-
Panjang tali pusat:…………….cm
-
Insersi : ………………….
-
Perdarahan : Kala I :………….cc
Kala II :………….cc
Kala III :………….cc
Selama operasi :…………………
Tindakan lain : ………………………………………………….
BAYI
Lahir : ……………………(Spt B, SC, VE,
dll)
Hari/Tanggal/Jam :…………………………………………………………………
BB/PB/AS :…………gr/……………cm/……….
Cacat bawaan :…………………………….
Masa gestasi :………………………minggu
2. Pemeriksaan Umum
a.
Keadaan umum :
lemah baik
b. Kesadaran
|
Compos mentis Apatis |
Somnolen  Sopor |
Koma |
c.
Keadaan emosional :
kooperatif
depresi agresif hipoaktif
bingung menarik diri cemas marah
hiperaktif
gelisah
d. Tanda –tanda vital
Tekanan darah : ……….. mmHg.
berbaring duduk berdiri
Nadi :
……….. kali/menit
teratur
tidak teratur
Pernafasan :
………. Kali / menit
teratur tidak
teratur dangkal dalam
Suhu : …….. 0C
aksila
oral rectal
3. Antropometri
¨
BB
sebelum Hamil : …….. kg
¨
BB
periksa yang lalu :
…… . kg
¨
BB sekarang : …….. kg
¨
Tinggi Badan :……… cm
¨
Lingkar Lengan Atas : …….. cm
4. Pemeriksaan Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)
a.
Wajah : ....................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
b.
Rambut : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
........................................................................................................................
c.
Mata : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
d.
Mulut & gigi : ..................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
e.
Telinga : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
f.
Hidung : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
g.
Dada : ...................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
h.
Mamae : ...................................................................................................
..........................................................................................................................
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i.
Abdomen :...................................................................................................
..........................................................................................................................
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j.
Genetalia : ....................................................................................................
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k.
Ekstremitas : ...................................................................................................
..........................................................................................................................
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5.
Pemeriksaan Laboratorium
a.
Darah: ………………………………………………………………………..
..........................................................................................................................
..........................................................................................................................
b.
Urine :
……….............................................................................................
..........................................................................................................................
..........................................................................................................................
6.
Pemeriksaan lain :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
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III. ASSESMENT
1. Interpretasi Data Dasar
a.
Diagnosa : ..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
b.
Masalah : ...................................................................................................
..................................................................................................
..................................................................................................
c.
Kebutuhan : ...................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
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..................................................................................................
2. Antisipasi terhadap
diagnosa/masalah potensial
.............................................................................................................................
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3. Identifikasi kebutuhan
akan tindakan segera/kolaborasi/rujukan
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IV. PLANNING
Tujuan :………
Kriteria Hasil : ………
……….
1. Intervensi
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No.
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Intervensi
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Rasionalisasi
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2. Implementasi
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No
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Hari/Tanggal/Jam
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Implementasi
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Paraf
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3.
Evaluasi : SOAP
|
No.
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Hari/Tanggal/Jam
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Evaluasi
|
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S : ………………………………………………..
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O: ……………………………………………….
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A: ……………………………………………….
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P : ……………………………………………….
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