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

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

 

2.       Keluhan utama

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

 

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

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

e.       Mobilisasi

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

 

8.       Riwayat kesehatan

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

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

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

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

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)

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

 

 

 

 

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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