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ASUHAN KEBIDANAN PADA IBU NIFAS
NY.N UMUR 25 TAHUN G1P1A0AH1 DENGAN .................................
DI........................................
NO. RESGISTER :...................................................................................
MASUK TANGGAL, JAM :...................................................................................
TEMPAT :...................................................................................
TANGGAL, JAM PENGKAJIAN DATA :.........................................................
Biodata Ibu Suami
Nama :...............................................................................................
Umur :...............................................................................................
Agama :...............................................................................................
Suku/Bangsa :...............................................................................................
Pendidikan :...............................................................................................
Pekerjaan :...............................................................................................
Alamat :...............................................................................................
Nomor Telpon/ HP :...............................................................................................
DATA SUBJEKTIF
1. Alasan Datang
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2. Keluhan Pasien
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3. Riwayat Menstruasi
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4. Riwayat Perkawinan
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5. Riwayat Obstetri
Hami
l ke -
Persalinan Nifas
LahirUmur
Kehamilan
Jenis
Persalinan
Penolon
g
Komplikasi J
K
BB
LahirLaktasi Komplikasi
Ibu Bayi
6. Riwayat Kehailan dan PersalinanTerakhir
Masa kehamilan :..................................................................................
Tempat Persalinan :..................................................................................
Komplikasi :..................................................................................
Placenta :..................................................................................
a. Lahir :..................................................................................
b. Ukuran/berat :..................................................................................
c. Tali pusat :..................................................................................
d. Kelainan :..................................................................................
Perinium :..................................................................................
Perdarahan Kala I
:..................................................................................
Kala II : .................................................................................
Kala III:..................................................................................
Kala IV:..................................................................................
Lama Persalinan Kala I : ..................................................................................
Kala II : .................................................................................
Kala III: .................................................................................
Kala IV: .................................................................................
Keadaan Bayi Baru Lahir
Lahir tanggal...........bulan........................tahun..............................
a. Masa Gastasi : .............................................................................................
b. BB/PB lahir : .............................................................................................
c. Nilai APGAR:1 menit/5 menit/10 menit/2 jam:...........................................
d. Cacat bawaan : .............................................................................................
e. Rawat gabung: .............................................................................................
7. Riwayat Kesehatan
a. Penyakit sistemik yang pernah/sedang diderita
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b. Penyakit yang pernah/sedang diderita keluarga
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8. Riwayat Kontrasepsi
No.Jenis
Kontrasepsi
Pasang Lepas
Tgl Oleh Tempat Keluhan Tgl Oleh Tempat Alasan
9. Riwayat Postpartum
Pola nutrisi : Makan Minum
Frekuensi ...................................................................................
Macam ...................................................................................
Jumlah ...................................................................................
Keluhan ...................................................................................
Minum obat dan Vitamin :..................................................................................
...................................................................................
Alergi :...................................................................................
...................................................................................
Pola eliminasi BAB BAK
Frekuensi ...................................................................................
Warna ...................................................................................
Bau ...................................................................................
Konsistensi ...................................................................................
Keluhan ....................................................................................
Mobilisasi dan permasalahan :......................................................................
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........................................................................
........................................................................
Keluhan jalan lahir :.......................................................................
.......................................................................
Lochea :.........................................................
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Kodisi pada jalan lahir :.......................................................................
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Pola tidur :...............................................................................................
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Aktifitas :..............................................................................................
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Personal hygine :...............................................................................................
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Kelancaran ASI :...............................................................................................
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Kebiasaan menyusu bayi :...................................................................................
...................................................................................
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Pola tidur bayi :...............................................................................................
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10. Kondisi Psiko Sosial Spiritual
Psiko Ibu :...............................................................................................
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Perawatan bayi :...............................................................................................
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Peran suami :..............................................................................................
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Peran keluarga :..............................................................................................
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Hubungan Ibu dengan Lingkungan : ..........................................................
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Spiritual :...............................................................................................
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