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KEMENTERIAN PENDIDIKAN NASIONAL

UNIVERSITAS SAM RATULANGI


FAKULTAS KEDOKTERAN
PROGRAM STUDI ILMU KEPERAWATAN
KAMPUS UNSRAT TLP.(0431)822016/3324407 FAX (0431)822016 SULAWESI UTARA

PENGKAJIAN INTRANATAL
I.

DATA UMUM
Inisial klien : ................ (.....th)

Nama Suami : .............................(......th)

Pekerjaan : ...............................

Pekerjaan : .............................................

Pendidikan Terakhir : ..............

Pendidikan terakhir :.............................

Agama : ...................................

Agama : .............................................

Suku bangsa :......................


Status perkawinan : ......................................................
Alamat : .........................................................................................................
II.

DATA UMUM KESEHATAN


TB/BB : ................cm/.................kg
BB sebelum hamil : .....................kg
Masalah kesehatan khusus : ...........................................................................
Obat-obatan : .................................................................................................
Alergi (obat/makanan/bahan tertentu) : .........................................................
Diet khusus : ..................................................................................................
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain-lain : .......................................................................................................
Frekuensi BAB/BAK :...................................................................................
Masalah BAB/BAK : ..............................................................................................
Kebiasaan waktu tidur : ..............................................................................................

III. DATA UMUM KEBIDANAN


Kehamilan sekarang direncanakan (ya/tidak)*
Status Obstetri : G ...........P.............A ............
HPHT : .................................Taksiran partus : ................................................
Jumlah anak di rumah : ..............................................
No

Jenis kelamin

Cara lahir

BB Lahir

Keadaan saat ini

Umur

Mengikuti kelas prenatal (ya/tidak) : ..............


Jumlah kunjungan ANC pada kehamilan ini : .......................................
Masalah kehamilan yang lalu : ....................................................................................
Masalah kehamilan sekarang : .....................................................................................
Rencana KB : .............................
Makanan bayi sebelumnya : ASI/PASI/lainnya*
Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi,/pernafasan/manfaat

ASI/cara

memberi

minum

botol/senam

nifas/metode

KB/perawatan

perineum/perawatan payudara/lain-lain, jelaskan .......................................................................................................


Setelah bayi lahir, siapa yang diharapkan membantu : .............................................
Masalah dalam persalinan yang lalu : ........................................................................
IV. RIWAYAT PERSALINAN SEKARANG
Mulai persalinan (kontraksi): tanggal/jam : ............................
Pengeluaran pervaginam (tanggal/jam) : ...............................
Keadaan

kontraksi

(frekuensi

dalam

10

menit,

lamanya,

.....................................................................................................................................
Denyut jantung janin :

Frekuensi ...................................
Kualitas : ...................................
Irama : .......................................

Pemeriksaan fisik :
Kenaikan BB selama hamil : .....................kg
TTV : TD......................mmHg,N.......................x/mnt S...............oC R..............x/mnt
Kepala dan leher :..................................................................................(normal/tidak)
Jantung : ......................................................................................................................
Paru-paru : ...................................................................................................................
Payudara : ...................................................................................................................
Abdomen : (secara umum dan pemeriksaan obstetrik) : ............................................
.....................................................................................................................................
Ekstremitas : edema/tidak ..........................................................................................
Refleks : ......................................................................................................................
Pemeriksaan dalam pertama : (jam) .......................oleh : ............................................
Hasil : ..................................... .....................................................................................
Ketuban : (utuh/pecah), jika sudah pecah : tgl/jam :...................................................
warna......................................................
Laboratorium : .............................................................................................................
..............................................................................................................

kekuatannya)

V.

DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : ............................................................................
Perasaan klien terhadap kehamilan sekarang : ..........................................................
Perasaan suami terhadap kehamilan sekarang : ........................................................
Jelaskan respon sibling terhadap kehamilan sekarang : .............................................

LAPORAN PERSALINAN
I.

Pengkajian awal
Tanggal : .........................Jam : ............................
TTV : TD......................mmHg,N.......................x/mnt S...............oC R..............x/mnt
Pemeriksaan palpasi abdomen
Leopold I : ..............................................................................
Leopold II : . ..............................................................................
Leopold III : ..............................................................................
Leopold IV : ..............................................................................
Hasil pemeriksaan dalam : ...............................................................................
Pemeriksaan perineum : .........................................................................................
Dilakukan klisma (ya/tidak) : .............
Pengeluaran pervaginam : ................................................................
Perdarahan pervaginam (ya/tidak) :.................
Kontraksi uterus (frekuensi, lamanya, kekuatan) : ................................................
DJJ : (frekuensi/kualitas)................................./.....................................................
Status janin : (hidup/tidak,jumlah,presentasi) : .....................................................
...............................................................................................................................

II.

Kala persalinan
Kala I
Mulai persalinan : (tanggal/jam)............................................................................
Tanda dan gejala : .................................................................................................
Lama Kala I : (jam/menit/detik)............................................................................
Keadaan psikososial : ...........................................................................................
Kebutuhan khusus klien : .....................................................................................
Tindakan : ............................................................................................................
Pengobatan : .........................................................................................................
Observasi kemajuan persalinan :
Tanggal/jam

Kontraksi uterus

DJJ

Keterangan

Kala II
Kala II dimulai : (Tgl/jam) : ...................................................................................
TTV : TD......................mmHg,N.......................x/mnt S...............oC R..............x/mnt
Lama kala II : (jam/menit/detik) ...................................................................................
Keadaan psikososial : ...................................................................................................
Kebutuhan khusus klien : .............................................................................................
Tindakan : .....................................................................................................................
Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur : ................................
Bonding ibu dan bayi :.......................
TTV bayi : TD......................mmHg,N...............x/mnt S...............oC R..............x/mnt
Pengobatan : .................................................................................................................
Catatan kelahiran :
Bayi lahir jam : .......................................
Jenis kelamin : ........................................
Nilai APGAR menit I................................menit V...........................
BB/PB/lingkar kepala : .........................gram.........................cm....................cm
Karakteristik khusus bayi : ..........................................................................................
Kaput suksadaneum/cephal hematoma : ......................................................................
Anus : berlubang/tertutup*
Perawatan tali pusat :..............................................................
Perawatan mata : ...................................................................
Kala III
Mulai jam : .................
TTV : TD......................mmHg,N.......................x/mnt S...............oC R..............x/mnt
Tanda dan gejala :...........................................................................................................
Plasenta lahir jam : ........................................................................................................
Cara lahir plasenta :.........................................................................
Karakteristik plasenta .....................................................................
Diameter : ..........cm
Ketebalan : .............cm
Panjang tali pusat : ..........................................................................
Jumlah pembuluh darah :.........................arteri .......................vena
Insersio tali pusat : ..........................................................................
Kelainan : ........................................................................................
Perdarahan : .........................ml
Karakteristik perdarahan : ...............................................................
Keadaan psikososial : ......................................................................
Kebutuhan khusus : .........................................................................
Tindakan : .......................................................................................
Pengobatan : ....................................................................................

Kala IV
Mulai jam : ................
TTV : TD......................mmHg,N.......................x/mnt S...............oC R..............x/mnt
Kontraksi uterus : ..........................................................................................................
Perdarahan :......................ml
Karakteristik : ...............................................................................................................
Tindakan : ....................................................................................................................

LAPORAN PARTUS NORMAL


SYAIR OBSTETRI
Nama Klien
:
Status Obstetri :
Tanggal / jam

Keterangan

Lampiran C

KEMENTERIAN PENDIDIKAN NASIONAL


UNIVERSITAS SAM RATULANGI
FAKULTAS KEDOKTERAN

PROGRAM STUDI ILMU KEPERAWATAN


KAMPUS UNSRAT TLP.(0431)822016/3324407 FAX (0431)822016 SULAWESI UTARA

FORMAT RESUME BAYI BARU LAHIR


Tanggal lahir bayi : .......................................
Proses Kelahiran bayi :

Perawatan bayi yang dilakukan :

Tanggal pengkajian : ...............................