FORMAT ASKEB PNC ( NIFAS )

 

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No. Register                                                    :  ………………………….............................

Masuk RS/PKM/BPM Tanggal/Pukul            : …………………………………………......

Dirawat di ruang                                             : ......................................................................

 

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

A.          Biodata                    Ibu                                        Suami

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

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

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

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

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

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

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

 

B.           Data Subjektif

1.       Alasan datang/dirawat

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2.       Keluhan utama

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3.       Riwayat menstruasi

Menarche       : .............................     Siklus              : ...................................

Lama              : .............................     Teratur             : ...................................

Sifat darah      : .............................     Keluhan           : ...................................

 

4.       Riwayat perkawinan

Status perkawinan      : ................      Menikah ke     : ..................................

Lama                          : ................      Usia menikah pertama kali     : ..........

 

5.       Riwayat obstetrik : P....A....Ah....

Hamil ke	Persalinan							Nifas
	Tanggal	Umur kehamilan	Jenis persalinan	Penolong	Komplikasi	JK	BB lahir	Laktasi	Komplikasi

 

 

6.       Riwayat kontrasepsi yang digunakan

No	Jenis kontrasepsi	Pasang				Lepas
		tanggal	oleh	tempat	keluhan	tanggal	oleh	Tempat	Alasan

7.       Pola pemenuhan kebutuhan masa nifas

a.       Nutrisi

Makan                                                      Minum

Frekuensi             : .....................             Frekuensi         : .................

Jenis                     : .....................             Jenis                : .................

Porsi                     : .....................             Porsi                : .................

Pantangan            : .....................             Pantangan       : .................

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

b.      Eliminasi

BAB                                                        BAK

Frekuensi             : .....................             Frekuensi         : .................

Warna                  : .....................             Warna              : .................

Konsistensi          : .....................             Konsistensi      : .................

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

c.       Istirahat

Tidur siang                                              Tidur malam

Lama        : ................................              Lama               : ....................

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

d.      Aktivitas

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e.       Mobilisasi

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8.       Riwayat kesehatan

a.       Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)

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b.       Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)

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c.       Riwayat operasi

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d.       Riwayat alergi obat

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9.       Kebiasaan yang mengganggu kesehatan (merokok, minum jamu, minuman beralkohol)

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10.   Data psikososial, spiritual dan ekonomi (penerimaan ibu/suami/keluarga terhadap kelahiran, dukungan keluarga, hubungan dengan suami/keluarga/tetangga, perawatan bayi, kegiatan ibadah, kegiatan sosial, keadaan ekonomi keluarga

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C.     Data Objektif

1.       Pemeriksaan umum

Keadaan umum          : ..............................    Kesadaran       : .......................

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

Tanda vital                 :

Tekanan darah           : .............mmHg          Nadi    : ...........x/menit

Pernafasan                  : ............x/menit          Suhu    : ...........x/menit

BB                              : ............kg                  TB       : ...........cm

          

2.       Pemeriksaan Fisik

Kepala            : .....................................................................................................

Wajah             : .....................................................................................................

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

Hidung           : .....................................................................................................

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

Telinga           : .....................................................................................................

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

Dada              : .....................................................................................................

Payudara        : .....................................................................................................

Abdomen       : .....................................................................................................

Ekstremitas   

Atas                : .....................................................................................................

Bawah            : .....................................................................................................

Genetalia        : .....................................................................................................

Jahitan dalam : .....................................................................................................

Jahitan luar     : .....................................................................................................

Lochea           : .....................................................................................................

Anus               : .....................................................................................................

 

3.       Pemeriksaan penunjang         Tgl       : ....................... Pukul : .........WIB

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4.       Data penunjang

Riwayat persalinan

Tanggal                      : ........................          Jam : .............................................

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

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

Plasenta                      : Lengkap/tidak

a.          Lahir                   : Spontan/tidak

b.         Berat                  : gram

c.          Tali pusat           : panjang : ..........cm   Insersio : .......................................

d.         Kelainan             : .........................................................................................

Perineum

a.          Robekan di         : .........................................................................................

b.         Jahitan dalam     : .........................................................................................

c.          Jahitan luar         : .........................................................................................

Lama Persalinan                                                        Perdarahan

Kala I             : ....................jam.............menit          ............. cc

Kala II           : ....................jam.............menit          ............. cc

Kala III          : ....................jam.............menit          ............. cc

Kala IV          : ....................jam.... ........menit          ............. cc

Total              : ....................jam.............menit          ............. cc

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

Nilai APGAR            : 1’ : ....... 5’ : ........... 10’ : ................

 

II.           INTERPRETASI DATA

A.    Diagnosa kebidanan

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Data Dasar:

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B.     Masalah

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Data Dasar:

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III.         IDENTIFIKASI DAN ANTISIPASI DIAGNOSA POTENSIAL

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IV.        TINDAKAN SEGERA

A.       Mandiri

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B.        Kolaborasi

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C.        Merujuk

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V.           PERENCANAAN        Tanggal : …………………. …….     Pukul : ……….....WIB

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VI.        PELAKSANAAN         Tanggal: ..........................................   Pukul : ................WIB

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EVALUASI                  Tanggal : ........................................... Pukul : .......... .....WIB

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	Pembimbing Institusi       .............................................		Pembimbing Institusi       .............................................		.............................................

 

PERTANYAAN SEPUTAR KEHAMILAN

 PERTANYAAN SEPUTAR KEHAMILAN 

berikut ini adalah beberapa contoh pertanyaan yang sering ditanyakan oleh ibu hamil:

MAKANAN 

T : Apa saja makanan yang perlu dihindari saat hamil  ?

J : Hindari konsumsi ikan mentah atau sushi, daging yang dimasak setengah matang, telur mentah atau setengah matang,karena dapat mengandung bakteri-bakteri yang membahayakan. pilih makanan yang aman dan sehat, selain itu kurangi makanan yang banayk mengandung lemak dan gula.

MINUMAN

T : Bolehkah ibu hamil sesekali mengonsumsi minuman beralkohol ?

J: Masa kehamilan bukanlah waktu yang tepat untuk mengonsumsi minuman beralkohol.ada suatu kelainan yang disebut dengan Fetal Alcojol Syndrome, yaitu cacat bawaan serius pada janin yang diakibatkan oleh konsumsi alkohol pada ibu hamil.

T : Bolehkah ibu hamil mengonsumsi secangkir kopi setiap hari?

J : Penelitian telah menemukan adanya kaitan antara konsumsi minuman berkafein dalam dosis besar ( lebih dari 300 mg- biasanya terkadang dalam 3 cangkir kopi atau lebih) setiap hari dengan nigren pada ibu hamil dan bayi dengan berat badan lahir rendah ( bblr). karena itu, jika tidak dapat dihindari sama sekali, ibu hamil masih boleh diperbolehkan minum kopi tetapi dalam jumlah yang dibatasi ddan tidak setiap hari.

T : Apakah teh herbal aman untuk ibu hamil ?

J : beberapa teh herbal diketahui justru dapat memicu terjadinya perdarahan dalam kehamilan atau persalinan prematur. jadi, karena tidak semua komposisi teh herbal diketahui dengan jelas, ibu hamil di anjurkan untuk tidak mengonsumsi minuman ini.

OBAT-OBATAN

T : obat apa saja yang aman di konsumsi ibu hamil ?

J : Obat obatan tertentu seperti antikonvulsan diketahui berhubungan dengan kelainan ( cacat) bawaan pada janin. minumlah obat-obatan yang diresepkan oleh dokter yang mengetahui kondisi ibu hamil

T : Bolehkah ibu hamil menggunakan obat anti jerawat ?

J : tetrasiklin, yaitu antibiotik yang biasanya digunakan untuk mengobati jerawat, juga diketahui berkaitan dengan terjadinya cacat bawaan.

ZAT KIMIA

T : Apakah aman untuk menggunakan obat semprot nyamuk dirumah ?

J : Obat pembasmi nyamuk tergolong pestisida yang merupakan racun bagi siapapun. zat ini diketahui berkaitan dengan kasus kelainan bawaan, seperti kelainan jantung bawaan dan cacat pada anggota tubuh janin. untuk amannya, ruangan yang baru disemprot oleh insektisida sebaiknya dibiarkan selama beberapa saat dengan ventilasi udara yang baik ( tidak tertutup rapat ) sebelum dimasuki.

PRODUK KECANTIKAN

T : bolehkah mengecat rambut selama hamil ?

J : Pengecatan rambut adalah salah satu hal yang masih kontroversi. substansi yang terkandung dalam prodak pewarna rambut dapat di absorpsi oleh pembuluh darahdi kulit kepala dan membahayakan janin didalam kandungan., selain itu pewarna rambut atau produk perawatan rambut biasanya mengandung ammonia yang membahayakan jika aroma terhirup ibu hamil. hingga saat ini belum ada penelitian yang membuktikan adanya hubungan antara penggunaan zat pewarna rambut dengan kasus abortus, kelainan bawaan, atau komplikasi lainnya.dilain pihak, tidak ada study yang membuktikan bahwa produk tersebut benar-benar bebas resiko. untuk amannya sebaiknnya tunda keinginan untuk mengecat rambut hingga bayi lahir.