Format Pengkajian Intranatal
DEPARTEMEN KEPERAWATAN MATERNITAS
PENGKAJIAN INTRANATAL
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Nama
Mahasiswa
NIM
|
:
...............................................
:
...............................................
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Tanggal
Pengkajian
Ruangan
/ RS
|
:
.................................................
:
.................................................
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DATA
UMUM KLIEN
Inisial Klien : ........................ ( ..... thn ) Nama suami :
........................ ( ..... thn )
Pekerjaan :
........................................ Pekerjaan : ........................................
Pendidikan terakhir : ........................................ Pendidikan terakhir : ........................................
Agama :
........................................ Agama :
........................................
Suku bangsa :
........................................ Status
Perkawinan : ........................................
Alamat :
.............................................................................................................................................
Alamat :
.............................................................................................................................................
DATA
UMUM KESEHATAN
1. TB/BB
: ........................................ cm/kg
2. BB
sebelum hamil : ........................................ kg
3. Masalah
kesehatan khusus : ........................................
4. Obat-obatan : ............................................................................................................................................................
: ............................................................................................................................................................
5. Alergi
(obat-obatan/makanan/bahan tertentu) : ........................................
6. Diet
khusus : ........................................
7. Alat
bantu yang digunakan : (gigi palsu / kacamata / lensa / alat dengar / tidak
ada)
8. Lain-lain,
sebutkan : ........................................
9. Frekuensi
BAK : ........................................, masalah :
........................................
10. Frekuensi
BAB : ........................................, masalah :
........................................
11. Kebiasaan
tidur : ........................................, masalah : ........................................
12. Kenaikan
BB selama kehamilan : ........................................
13. Tanda
vital : TD : .................... mmHg. Nadi .................... x/menit. Suhu
...............
. RR ............... x/menit
14. Kepala
dan leher : (normal / tidak)
15. Jantung
: ....................................................................................................................................................................
16. Paru-paru
: .................................................................................................................................................................
17. Payudara
: .................................................................................................................................................................
18. Abdomen
(secara umum dan pemeriksaan obstetrik :
..............................................................................................
...................................................................................................................................................................................
19. Kontraksi
: ..............................................................................................................
DJJ : ........................................
20. Refleks
: ....................................................................................................................................................................
21. Ekstremitas
( edema / tidak ) : ..................................................................................................................................
Pemeriksaan dalam pertama : jam
........................................ oleh
...........................................................................
Hasil :
........................................................................................................................................................................
22. Ketuban
: ( utuh / pecah ) jika pecah : tgl/jam : ........................................
warna : ........................................
23. Laboratorium
: ..........................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
DATA
PSIKOSOSIAL
1. Penghasilan
keluarga tiap bulan : Rp
........................................................................................................................
2. Persaan
klien terhadap kehamilan sekarang :
...........................................................................................................
3. Perasaan
suami terhadap kehamilan sekarang :
........................................................................................................
4. Jelaskan
respon sibling terhadap kehamilan sekarang : ............................................................................................
LAPORAN
PERSALINAN
PENGKAJIAN AWAL
1. Tanggal:
........................................................... jam
...........................................................
2. Tanda-tanda
vital: TD : .................... mmHg. Nadi ............... x/menit. Suhu
...............
. RR ............... x/mnt
3. Pemeriksaan
palpasi abdomen ..................................................................................................................................
4. Hasil
periksa dalam :
................................................................................................................................................
5. Persiapan
perineum :
................................................................................................................................................
6. Dilakukan
klisma : ( ya / tidak ), jelaskan ................................................................................................................
7. Pengeluaran
pervaginam ...........................................................................................................................................
DATA
UMUM KEBIDANAN
1. Kehamilan
sekarang direncanakan ( ya / tidak ) :
.....................................................................................................
2. Status
Obstetrik : G ............ P ............ A ............ H ............. UK
............. minggu
3. HPHT
: .................................................. Taksiran partus :
..................................................
4. Jumlah
anak di rumah : ..................................................
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No
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Jenis
Kelamin
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Cacat
Lahir
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BB
Lahir
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Keadaan
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Umur
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5. Mengikuti
kelas prenatal ( ya / tidak ) : ....................................................................................................................
6. Jumlah
kunjungan ANC pada kehamilan ini :
..........................................................................................................
7. Masalah
kehamilan yang lalu :
.................................................................................................................................
8. Masalah
kehamilan sekarang : ..................................................................................................................................
9. Rencana
KB :
............................................................................................................................................................
10. Makanan
bayi sebelumnya : ASI / PASI / lainnya :
.................................................................................................
11. Pelajaran
yang diinginkan saat ini : relaksasi / pernapasan / manfaat ASI / cara memberi
minum dengan botol / senam nifas / metode KB / perawatan perineum perawatan
payudara / lain-lain : ...................................................
Jelaskan :
...................................................................................................................................................................
12. Setelah
bayi lahir, siapa yang diharapkan membantu : ( suami / teman / tetangga )
13. Masalah
dalam persalinan yang lalu : .......................................................................................................................
RIWAYAT PERSALINAN SEKARANG
1. Mulai
persalinan ( kontraksi / pengeluaran pervaginam ) tgl/jam ............................................................................
2. Keadaan
kontraksi: frekuensi dalam 10 menit ...................., lamanya
...................., kekuatan ....................
3. Denyut
jantung janin: frekuensi: .............................., kualitas:
...................., keteraturan: ..............................
4. Pemeriksaan
fisik:
Perdarahan pervaginam ( ya / tidak ),
jelaskan:
........................................................................................................
Kontraksi uterus: frekuensi
.............................., lamanya ..............................,
kekuatan ..............................
Denyut jantung janin: frekuensi:
.............................., kualitas: ..........................................
Status janin ( hidup / tidak), jumlah
........................., presentasi ..............................
KALA
PERSALINAN
·
KALA I
1. Mulai
persalinan tanggal: .................................................. jam :
..................................................
2. Tanda
dan gejala : ..................................................
3. Tanda-tanda
vital: TD : .................... mmHg. Nadi .......... x/menit. Suhu ..........
. RR .......... x/mnt
4. Lama
kala I:
.............................. jam .............................. menit
.............................. detik
5. Keadaan
psikososial:
.........................................................................................................................................
6. Kebutuhan
khusus klien: ...................................................................................................................................
7. Tindakan:
...........................................................................................................................................................
8. Pengobatan:
.......................................................................................................................................................
Pengobatan:
.......................................................................................................................................................
·
KALA II
1. Mulai
persalinan tanggal: .................................................. jam :
..................................................
2. Tanda
dan gejala : ..................................................
3. Tanda-tanda
vital: TD : .................... mmHg. Nadi .......... x/menit. Suhu ..........
. RR .......... x/mnt
4. Lama
kala II: .............................. jam ..............................
menit .............................. detik
5. Keadaan
psikososial:
.........................................................................................................................................
6. Kebutuhan
khusus klien:
...................................................................................................................................
7. Tindakan:
...........................................................................................................................................................
·
KALA III
1. Tanda
dan gejala: ...............................................................................................................................................
2. Plasenta
lahir jam
...............................................................................................................................................
3. Cara
lahir plasenta:
............................................................................................................................................
4. Krakter
plasenta:
Ukuran ..............................
cm x .............................. cm x .............................. cm
Panjang tali pusat
...............................................................................................................................................
Jumlah pembuluh darah
........................................ arteri
........................................ vena
5. Perdarahan:
.................................................. ml. Karakteristik .........................................................................
6. Keadaan
psikososial: .........................................................................................................................................
7. Kebutuhan
khusus: ............................................................................................................................................
8. Tindakan:
: .........................................................................................................................................................
9. Pengobatan:
.......................................................................................................................................................
Pengobatan:
.......................................................................................................................................................
·
KALA IV
1. Mulai
jam
...........................................................................................................................................................
2. Tanda-tanda
vital: TD : .................... mmHg. Nadi .......... x/menit. Suhu ..........
. RR .......... x/mnt
3. Kontraksi
uterus .................................................................................................................................................
4. Perdarahan:
.................................................. ml. Karakteristik
.........................................................................
5. Bonding
ibu dan bayi
.........................................................................................................................................
6. Tindakan:
...........................................................................................................................................................
·
BAYI
1. Bayi
lahir tanggal/jam
.......................................................................................................................................
2. Jenis
kelamin .....................................................................................................................................................
3. Nilai
APGAR
|
Tanda
|
Nilai
|
∑
|
||
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0
|
1
|
2
|
||
|
·
Denyut jantung
|
(
) tidak ada
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(
) < 100
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(
) > 100
|
|
|
·
Usaha napas
|
(
) tidak ada
|
(
) lambat
|
(
) menangis kuat
|
|
|
·
Tonus otot
|
(
) lumpuh
|
( ) ekstremitas fleksi sedikit
|
(
) gerakan aktif
|
|
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·
Iritabilitas reflek
|
(
) tidak bereaksi
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(
) gerakan sedikit
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( ) reaksi melawan
|
|
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·
Warna
|
(
) biru/pucat
|
( ) tubuh kemerahan, tangan dan kaki biru
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(
) kemerahan
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TOTAL
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|||
4. BB
bayi ............... gram, PB bayi .......... cm, LK bayi .......... cm, LD
bayi .......... cm, LLA bayi .......... cm
5. Karakteristik
khusus bayi: .................................................................................................................................
6. Kaput:
suksedanium / chepal hematom , ...........................................................................................................
7. Tanda-tanda
vital: TD : .................... mmHg. Nadi .......... x/menit. Suhu ..........
. RR .......... x/mnt
8. Anus
...................................................................................................................................................................
9. Perawatan
tali pusat
...........................................................................................................................................
10.
Perawatan mata
..................................................................................................................................................
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