Intra Natal

ASUHAN KEPERAWATAN PADA Ny

DENGAN ..
Di RUANG VK
RS/BKIA .
TANGGAL .

A. PENGKAJIAN KALA I
I.

IDENTITAS PASIEN
Nama

: ........................................

Umur

: ........................................

Pendidikan

: ........................................

Pekerjaan

: ........................................

Status perkawinan : .......................................

Agama

: .......................................

Suku

: .......................................

Alamat

: .......................................

No. CM

: .......................................

Tanggal MRS

: ........................................

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

Sumber Informasi : ........................................
PENANGGUNG/ SUAMI
Nama

: ........................................

Umur

: ........................................

Pendidikan

: ........................................

Pekerjaan

: ........................................

Alamat

: ........................................

II. ALASAN DIRAWAT

Keluhan utama (saat MRS dan sekarang)
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III. RIWAYAT OBSTETRI DAN GINEKOLOGI

a.

Riwayat Menstruasi :
Menarche

: umur .................

Siklus

: teratur ( )

tidak ( )

Banyaknya

: ...........................

Lamanya

: ..............................

Keluhan : ...........................
HPHT
b.

: ...........................

Riwayat Pernikahan :
Menikah : ................. kali

c.

Lama : ............... tahun

Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke

Kehamilan
Umur

No

Tahun

d.

Riwayat kehamilan saat ini :

Kehamilan

Penyulit

Persalinan
Jenis

Penolong

Komplikasi Nifas

Penyulit

Laserasi

Infeksi

Perdarahan

Anak
Jenis
Kelamin

Status obstetrikus :

G........ P........ A.......... H..........

TP : ...................

ANC kehamilan sekarang : ...........................(tuliskan riwayat ANC pada

kehamilan sekarang)

e.

UK : ................... minggu

Riwayat Keluarga Berencana :

Akseptor KB

: jenis .....................

Masalah

: .............................

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

BB

Pj

f.

Riwayat Penyakit Klien dan Keluarga

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

IV.

POLA FUNGSIONAL KESEHATAN

a.

Pemeliharaan dan persepsi terhadap kesehatan

..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
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..........................................................................................................................
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b.

Nutrisi/ metabolic
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..............................

c.

Pola eliminasi
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.........................

d.

Pola aktivitas dan latihan

Kemampuan perawatan diri

Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total
Keterangan :

e.

Pola tidur dan istirahat

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

f.

Pola perseptual
..........................................................................................................................
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g.

Pola persepsi diri

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

h.

Pola seksual dan reproduksi

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

i.

Pola peran-hubungan
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
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..............................

j.

Pola manajemen koping stress

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

k.

Sistem nilai dan keyakinan

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

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V. PEMERIKSAAN FISIK
Keadaan Umum
GCS

.........................................................................................................
Tingkat Kesadaran :
.........................................................................................................
Tanda-tanda vital : TD ............... N ................. RR ............... T...........
BB

: ..................... TB ................ LILA : ......................

Head to toe
Kepala wajah

Mata

Leher

Dada

Payudara

Inspeksi :
Areola .................

Puting : (menonjol/tidak)

Tanda dimpling/retraksi : ....................................

Palpasi : Pengeluaran ASI ...................... Adanya nodul :
...........................
Jantung:

Inspeksi:
..............................................................................................................................
......

Palpasi:
..............................................................................................................................
......

Perkusi:
..............................................................................................................................
..............................................................................................................................

Auskultasi:
..............................................................................................................................
..............................................................................................................................

Paru :

Inspeksi:
..............................................................................................................................
..............................................................................................................................

Palpasi:
..............................................................................................................................
..............................................................................................................................

Perkusi:
..............................................................................................................................
......

Auskultasi:
.........................................................................................................................................
.........................................................................................................................................
............

Abdomen :

Inspeksi: Linea : ................. Striae : ................

Luka

bekas

operasi

..............
Kontraksi : ...................
Pembesaran sesuai UK : ....................

Gerakan

janin

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

Auskultasi: DJJ :

Palpasi:
Leopold I

: .

TFU

Leopold II

: Kanan : .
Kiri

: ..

Leopold III

: ..

Leopold IV

: ..

Penurunan kepala

..

(penurunan

bagian

terbawah dengan metode lima jari)

Kontraksi

: x/ 10 menit Durasi :

..

Perkusi:
..............................................................................................................................
..............................................................................................................................
............

Genetalia dan Perineum :

Kebersihan

Bloody show : ...........................................................................................

VT

: ..........................................................................................

: ...........................................................................................

Anus :
Hemoroid : .....................................................................................................
Ekstremitas :
Atas dan bawah (hasil dibuat terpisah)
(oedema, varises, CRT, kekuatan otot, tonus)

VI. DATA PENUNJANG

a.

Data laboratorium yang berhubungan

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b.

Pemeriksaan USG
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c.

VII.

Lampirkan Pantograf

DIAGNOSA MEDIS
..............................................................................................................................
..............................................................................................................................
............

VIII.

PENGOBATAN
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
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............

B. ANALISA DATA KALA I

DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN KALA I

RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI KALA I
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN KALA I

NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

PENGKAJIAN KALA II
A. PENGKAJIAN DATA FOKUS (subjektif dan objektif)
DATA SUBJEKTIF

DATA OBEKTIF

B. ANALISA DATA KALA II

DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN KALA II

RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI KALA II
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN KALA II

NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

PENGKAJIAN KALA III

A. PENGKAJIAN DATA FOKUS (subjektif dan objektif)
DATA SUBJEKTIF

DATA OBEKTIF

B. ANALISA DATA KALA III

DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN KALA III

RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI KALA III

TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN KALA III

NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

PENGKAJIAN KALA IV
A. PENGKAJIAN DATA FOKUS (subjektif dan objektif)
DATA SUBJEKTIF

DATA OBEKTIF

B. ANALISA DATA KALA IV

DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

1. ..
2. ..
3. ..

C. RENCANA KEPERAWATAN KALA IV

RENCANA KEPERAWATAN
NO

DIAGNOSA
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI KALA IV
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGAN KALA IV

NO

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI
S:

O:

A:

P:

PARAF

Mengetahui,
Pembimbing klinik/CI
Mahasiswa

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

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

NIP.

NIM.
Clinical Teacher/ CT

...............................................
NIP.