KEMENTERIAN KESEHATAN RI

BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN

POLITEKNIK KESEHATAN MATARAM
Jalan Prabu Rangkasari Dasan Cermen Cakranegara-Mataram
Telepon (0370) 631160-621383 Faximile (0370) 621383
Website: www.poltekkesmataram.ac.id, Email:admin@poltekkesmataram.ac.id

ASUHAN KEBIDANAN POSTPARTUM PATOLOGIS

DENGAN ……………………………
DI..............................

Tanggal Pengkajian : ..........................................................

Jam : ..........................................................
Tempat pengkajian : ..........................................................

A. DATA SUBJEKTIF
1. Identitas
Nama Ibu : ......................... Nama Suami : .........................
Umur : ....... Tahun Umur : ....... Tahun
Pendidikan : ......................... Pendidikan : .........................
Agama : ......................... Agama : .........................
Pekerjaan : ......................... Pekerjaan : .........................
Alamat : .....................................................................................

2. Alasan Kunjungan
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3. Keluhan utama
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4. Riwayat Perjalanan Penyakit
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 5. Tanda Bahaya Nifas
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6. Riwayat kesehatan
a. Riwayat kesehatan dahulu
1) Jantung : ..........................................................
2) Asma : ..........................................................
3) TBC : ..........................................................
4) Ginjal : ..........................................................
5) DM : ..........................................................
6) Malaria : ..........................................................
7) HIV / AIDS : ..........................................................
b. Riwayat kesehatan sekarang
1) Jantung : ..........................................................
2) Hipertensi : ..........................................................
3) TBC : ..........................................................
4) Ginjal : ..........................................................
5) DM : ..........................................................
6) Malaria : ..........................................................
7) HIV / AIDS : ..........................................................
c. Riwayat kesehatan keluarga
1) Jantung : ..........................................................
2) Asma : ..........................................................
3) Hipertensi : ..........................................................
4) TBC : ..........................................................
5) Ginjal : ..........................................................
6) DM : ..........................................................
7) Malaria : ..........................................................
8) HIV / AIDS : ..........................................................
9) Kembar : ..........................................................

7. Riwayat perkawinan
Nikah......x, umur......tahun, dengan suami umur...... tahun, lama
pernikahan.................
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 8. Riwayat Obstetri
a. Riwayat Menstruasi
Menarche : ..........................................................
Siklus : ..........................................................
Lama : ..........................................................
Banyaknya darah : ..........................................................
Bau : ..........................................................
Warna : ..........................................................
Konsistensi : ..........................................................
Keluhan : ..........................................................
Flour albus : ..........................................................

b. Riwayat kehamilan, persalinan dan nifas yang lalu

Hamil UK Tempat Penolon Jenis Penyulit BBL Ket
ke Persalinan g Persalina H P N BB JK Usi
n a

c. Riwayat Persalinan Sekarang

1. Tanggal/jam persalinan : ..............................................................
2. Penolong persalinan : ..............................................................
3. Tempat persalinan : ..............................................................
4. Jenis persalinan (spontan, vakun, SC) : ......................................
5. Keadaan bayi ( BB/PB bayi,Jenis kelamin, hidup/mati) :
......................................................................................................
6. Komplikasi selama kehamilan dan persalinan : ..........................
7. Robekan jalan lahir/episiotomi : .................................................
d. Riwayat Psikososial
a. Konsumsi zat besi : .............................................................
b. Konsumsi Obat-obatan : .............................................................

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 c. Kebutuhan Nutrisi/diet
1) Frekuensi : ........................................................................
2) Komposisi : ........................................................................
3) Porsi : ........................................................................
4) Pantangan : ........................................................................
5) Masalah : ........................................................................
d. Pemberian ASI
1) Frekuensi : ........................................................................
2) Lamanya : ........................................................................
3) Kesulitan : ........................................................................
e. Pola Eliminasi (BAK & BAB)
1) Frekuensi : ........................................................................
2) Konsistensi: ........................................................................
3) Warna : ........................................................................
4) Kesulitan : ........................................................................
f. Istirahat
1) Lama : ........................................................................
2) Kesulitan : ........................................................................
g. Ketidaknyamanan Nyeri
1) Lokasi : ........................................................................
2) Intesitas : ........................................................................
3) Cara mengatasi nyeri : ........................................................
h. Mobilisasi
1) Duduk : ......................................................................
2) Berdiri : ......................................................................
3) Berjalan : ......................................................................
i. Personal Hygiene
1) Mandi : ...................................................................
2) Gosok gigi : ...................................................................
3) Ganti pakaian : ...................................................................
j. Hubungan seksual
1) Kenyamanan fisik : ..........................................................
2) Kenyamanan emosi : ..........................................................
k. Psikologi
1) Respon Ibu terhadap diri sendiri : ......................................
.............................................................................................
2) Respon Ibu terhadap bayi: .................................................
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 3) Respon Kelurga terhadap Ibu dan Bayi : ...........................
............................................................................................
l. Riwayat Sosial Ekonomi
1) Status perkawinan : ................................................
2) Lama perkawinan : ................................................
3) Jumlah anggota kelurga dalam satu rumah: ......................
4) Riwayat dan rencana KB : ................................................

B. DATA OBJEKTIF
1. Pemeriksaan Umum
a. Keadaan Umum : .......................................
b. Kesadaran : .......................................
c. TTV
Td : .......................mmHg
N : .......................x/menit
R : .......................x/menit
S : ........................˚C
d. BB : ..............kg, sekarang..............kg
TB : ..............cm
LILA : ..............cm

2. Pemeriksaan fisik
a. Kepala : warna rambut hitam, distribusi merata, bersih, lesi / massa ( )
b. Muka : simetris, pucat ( ),oedema ( )
c. Mata : konjungtiva anemis ( ), sclera ikterik ( )
d. Hidung : polip hidung ( ), pengeluaran abnormal ( )
e. Telinga : pengeluaran abnormal ( ), cerumen ( )
f. Mulut : bibir.........................., stomatitis ( ), caries dentis ( )
g. Leher : bendungan vena jugularis ( ), pembesaran kelenjar tiroid ( ),
pembesaran kelenjar limfe ( )
h. Dada : simetris, pengeluaran ASI......................, putting susu menonjol ( ),
retraksi /dimpling ( ), massa ( )
i. Ketiak : pembesaran kelenjar limfe ( )
j. Abdomen :
1) luka bekas operasi : .................................................
2) kandung kemih : .................................................
3) Kontraksi : .................................................
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 4) TFU : .................................................
5) Massa/konsistensi/otot parut : ................................................
k. Genitalia :
1) Keadaan labia mayor dan minor (luka, cairan) : ......................
2) Perineum (luka laserasi, jahitan perinium) : ......................
3) Lokhea (warna, konsistensi, bau) : .......................
l. Ekstremitas atas : simetris, oedema ( ), pucat pada kuku ( )
m. Ekstremitas bawah : simetris, varises ( ), oedema ( ), pucat pada kuku ( ), reflex
patella ( )
n. Anus : hemoroid ( )

3. Pemeriksaan penunjang
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C. ANALISA
1. Diagnosa kebidanan
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2. Masalah
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3. Kebutuhan
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D. PENATALAKSANAAN Tanggal :....................................., Pukul :..............wita

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Mengetahui,
Mahasiswa Pelaksana

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