ASUHAN KEBIDANAN PADA IBU NIFAS

NO. REGISTER                                 : …………………………...........................................

MASUK RS TANGGAL, JAM         : ……………………………………………………...

Masuk Ruang Nifas                            : ..................................................................................

DIRAWAT DI RUANG                    : ...................................................................................

I.              PENGKAJIAN DATA, Oleh:..........................................Tanggal/Jam: .......................

A.    Biodata                    Ibu                                        Suami

1.       Nama              : ..........................................    .................................................

2.       Umur              : ..........................................    .................................................

3.       Agama            : ..........................................    .................................................

4.       Suku/bangsa   : ..........................................    .................................................

5.       Pendidikan     : ..........................................    .................................................

6.       Pekerjaan        : ..........................................    .................................................

7.       Alamat           : ..........................................    .................................................

B.     Data Subjektif

1.       Alasan masuk rumah sakit

..................................................................................................................................................................................................................................................

2.       Riwayat persalinan

Tempat persalinan      : ...................................................................................

Jenis persalinan          : spontan/tindakan: .....................................................

                                     Atas indikasi: ............................................................

Penolong                    : ...................................................................................

Komplikasi                 : ...................................................................................

·         Partus lama           : ................................jam

·         KPD                     : ................................jam

Plasenta                       : lengkap/tidak

·         Lahir                    : spontan/manual

·         Ukuran/Berat       : ...................................................................................

·         Tali pusat             : panjang ..............cm, insersio: ..................................

·         Kelainan               : ...................................................................................

Perineum                     : utuh / ruptur (derajat 1/2/3/totalis) / episiotomi   (medialis / lateralis / mediolateralis)

                                      Jahitan dalam ................... benang ...........................

                                      Jahitan luar ...................... benang ............................

Perdarahan                    Kala I .................... cc

                                      Kala II ................... cc

                                      Kala III .................. cc

                                      Kala IV .................. cc

                                      Selama operasi ..................... cc

Tindakan lain             : Infus ..........................................................................

                                     Tranfusi darah ...........................................................

Lama persalinan            Kala I .....................jam ...................menit

                                      Kala II ................... jam ...................menit

                                      Kala III .................. jam ...................menit

                                      Kala IV .................. jam ...................menit

                                      Operasi ................... jam ...................menit

3.       Keadaan bayi baru lahir

Lahir tanggal....................................... jam .................................................

Masa gestasi   : ................................... minggu

BB/PB lahir    :................................................................................................

Nilai APGAR : 1 menit/5 menit/10 menit/2 jam: ....... /........ /....... /........       

Cacat bawaan : ...............................................................................................

4.       Riwayat post partum

Pola tidur                   : ...................................................................................

Pola eliminasi            

·         BAB                     : ...................................................................................

·         BAK                    : ...................................................................................

Pengalaman menyusui ...................................................................................

5.       Lingkungan sosial     

Orang terdekat           : ...................................................................................

Tinggal serumah dengan ................................................................................

Tanggapan keluarga   : ...................................................................................

Rencana perawatan bayi ................................................................................

6.       Keluhan sekarang     

................................................................................................................................................................................................................................................

7.       Riwayat kehamilan, persalinan dan nifas yang lalu

Hamil ke	Persalinan							Nifas
	Tgl lahir	Umur kehamilan	Jenis persalinan	penolong	komplikasi	Jenis kelamin	BB lahir	laktasi	komplikasi

8.       Riwayat kontrasepsi yang digunakan

No	Jenis kontrasepsi	Pasang				Lepas
		tanggal	oleh	tempat	keluhan	tanggal	oleh	tempat	alasan

9.       Riwayat kesehatan

a.       Penyakit yang pernah/sedang diderita

....................................................................................................................................................................................................................................

b.       Penyakit yang pernah/sedang diderita keluarga

....................................................................................................................................................................................................................................

                 10. Data pengetahuan pasien tentang:

a. Cara menyusui yang benar                        :

b. Perawatan BBL                                         :

c. Senam Nifas                                              :

d.Tanda pathologi Nifas dan BBL                :

e. Keluarga Berencana                                   :

C.     Data Objektif

1.       Pemeriksaan Fisik

a.       Keadaan umum .............................. kesadaran ........................................

b.       Status emosional  : ...................................................................................

c.       Tanda vital

Tekanan darah     : ...................................................................................

Nadi                     : ...................................................................................

Pernafasan           : ...................................................................................

Suhu                     : ...................................................................................

d.       BB/TB                 : ...................................................................................

e.       Kepala dan leher 

Oedem wajah       : ...................................................................................

Mata                     : ...................................................................................

Mulut                   : ...................................................................................

Leher                    : ...................................................................................

f.        Payudara

Bentuk                 : ...................................................................................

Benjolan               : ...................................................................................

Puting susu          : ...................................................................................

Pengeluaran         : ...................................................................................

Keluhan               : ...................................................................................

g.       Abdomen

Dinding perut       : ...................................................................................

Bekas luka           : ...................................................................................

TFU                     : ...................................................................................

                               Kontraksi             : ...................................................................................

h.       Tangan dan kaki

Oedem                 : ...................................................................................

Varices                 : ...................................................................................

 Reflek patela       : ...................................................................................

Kuku                    : ...................................................................................

i.         Genetalia luar      

Udem                   : ...................................................................................

Varices                 : ...................................................................................

Bekas luka           : ...................................................................................

Jahitan                  : .................................................................................

Pengeluaran         : ...................................................................................

j.         Anus                    : Hemoroid / tidak

2.       Pemeriksaan Penunjang

a.       Pemeriksaan Laboratorium

Darah, tanggal:               

Hasil ........................................................................................................

....................................................................................................................................................................................................................................

Urine, tanggal:

Hasil ........................................................................................................

....................................................................................................................................................................................................................................

b.       Catatan Medik lain

..................................................................................................................

..................................................................................................................

II.           INTERPRETASI DATA

A.    Diagnosa kebidanan

..............................................................................................................................................................................................................................................................

Data Dasar:

.............................................................................................................................................................................................................................................................................................................................................................................................

B.     Masalah

..............................................................................................................................................................................................................................................................

Data Dasar:

............................................................................................................................................................................................................................................................................................................................................................................................

C.     Kebutuhan

..............................................................................................................................................................................................................................................................

Data Dasar:

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III.         IDENTIFIKASI DIAGNOSA/MASALAH POTENSIAL DAN ANTISIPASI PENANGANAN

A.    Diagnosa Potensial

..............................................................................................................................................................................................................................................................

Data Dasar:

............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

B.     Masalah Potensial

..............................................................................................................................................................................................................................................................

Data Dasar:

..............................................................................................................................................................................................................................................................

IV.        MENETAPKAN KEBUTUHAN TERHADAP TINDAKAN SEGERA BERDASARKAN KONDISI KLIEN

A.    Mandiri

..............................................................................................................................................................................................................................................................

B.     Kolaborasi

..............................................................................................................................................................................................................................................................

C.     Merujuk

..............................................................................................................................................................................................................................................................

V.           RENCANA ASUHAN YANG MENYELURUH, tanggal ............................jam .......

a.              .............................................................................................................................

b.             ..............................................................................................................................

c.              ..............................................................................................................................

d.             .............................................................................................................................

VI.        IMPLEMENTASI

Tanggal ............................... jam ..........                                                           

a.              .............................................................................................................................

b.             ..............................................................................................................................

c.              ..............................................................................................................................

d.             ..............................................................................................................................

VII.      EVALUASITanggal ............................... jam ..........   

a.              .............................................................................................................................

b.             ..............................................................................................................................

c.              ..............................................................................................................................

d.             .............................................................................................................................

Metode dokumentasi SOAP

Judul Askeb       :

Nama pasien      : 

Nama suami       :

Tempat dirawat :

Data Subjektif	Data Objektif	Assassment	Plan