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PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA

PERIODE INTRANATAL

Nama Mahasiswa
Nomor Mahasiswa
Tanggal pengkajian
Tempat Praktek
Tanggal Praktek

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

DATA UMUM
Inisial Klien
Umur
Pekerjaan
Pendidikan Terakhir
Suku bangsa
Status perkawinan

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

Nama Suami
Alamat
Pekerjaan
Agama
Pendidikan terakhir

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

DATA UMUM KESEHATAN


1. Tinggi / berat badan...cm/
kg
2. Berat badan sebelum hamil .....kg
3. Masalah kesehatan khusus
4. Obat obatan

5. Alergi (makanan / obat-obatan / bahan tertentu


..............................
6. Diet khusus
.............................
7. Menggunakan alat bantu : gigi tiruan / kaca mata / kontak lensa / alat
dengar, lain-lain, sebutkan

8. Frekuensi BAB .. kali/ hari, masalah


..

9. Frekuensi BAK . Kali / hari, masalah


..
10. Kebiasaan waktu tidur

.
DATA UMUM MATERNITAS
1. Kehamilan sekarang direncanakan ( ya/tidak) :
2. Status Obstetrikus : GP.A.. Usia kehamilan
.
3. HPHT . Tafsiran partus
..
4. Jumlah anak dirumah
.
NO

Jenis
Kelamin

Cara
lahir

Tempat
persalinan
dan
penolong

BB
lahir

Komplikasi
selama
proses
persalinan

Keadaan
saat ini

Umur

5. Mengikuti kelas prenatal ( ya / tidak )

6. Jumlah kunjungan selama kehamilan ini

7. Masalah kehamilan yang lain


..
a. Trimester I
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b. Trimester II
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c. Trimester III
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8. Masalah kehamilan sekarang

9. Kontrasepsi yang pernah dipakai dan masalah yang pernah dialami selama
penggunaan alat konterasepsi ini .

..
Rencana KB setelah kehamilan ini

...................................................
10. Makanan bayi sebelumnya ASI / PASI

..
11. Pendidikan kesehatan yang ingin ibu dapatkan selama perawatan (Lingkari
tanda didepan opstion)
Relaksasi pernafasan
Manfaat ASI dan cara menyusui yang baik
Senam nifas
Metode KB
Perawatan perineum
Perawatan payudara
Setelah bayi lahir siapa yang diharapkan membantu : suami / teman / orang tua
atau yang lain
Masalah persalinan yang lalu

RIWAYAT PERSALINAN SEKARANG


1. Mulai persalinan (konmtraksi / pengeluaran pervaginam ) : tgl
/jam......
..................................................................................
...
2. Keadaan kontraksi (frekuensi dalam 10 mnt,lamanya , kekuatan ).....................
......
3. Frekuensi dan kekuatan denyut jantung janin ..x/ mnt
4. Pemeriksaan fisik :
Kenaikan BERAT BADAN selam kehamilan .kg
Tanda vital : TD = mmHg ; Nadi = ..x /mnt ; suhu = C; P=
x/mnt
Kepala / leher
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Dada (jantung, paru-paru)
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Payudara
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Abdomen (secara umum dan pemeriksaan)
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Kontraksi
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DJJ
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Ekstrimitas (edema / tidak)
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Refleks
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5. Pemeriksaan dalam
Jam pemeriksaan
Oleh
Hasil
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6. Ketuban (utuh / pecah ) jika sudah pecah tgl /jam ..Warna


..
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7. Laboratorium
Tanggal dan jenis
pemeriksaan
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Hasil pemeriksaan
normal

Interpretasi

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Terapi yang diberikan


Tanggal

Jenis terapi

Rute
terapi

Dosis

Indikasi terapi
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DATA PSIKOSOSIAL

Penghasilan keluarga setiap bulan : Rp

Bagaimana perasaan anda terhadap kehamilan sekarang


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Bagaimana perasaan pasangan anda terhadap kehamilan sekarang
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Jelaskan respon sibling terhadap kehamilan sekarang
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LAPORAN PERSALINAN
Kala I
Tanggal

Jam

Hasil Observasi

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Nama klien
Umur
No
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ANALISA DATA
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Data (Symptom)
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Penyebab

Masalah

(Etiologi)

(Problem)

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IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN


No.
Dx
Kep

Waktu
Tgl/jam

Tindakan
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TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)
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TT

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Kala 2
Tanggal

Jam

Hasil Observasi
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Nama klien
Umur
No
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ANALISA DATA
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Data (Symptom)
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Penyebab

Masalah

(Etiologi)

(Problem)

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Keadaan Umum bayi baru lahir


o Berat badan
:
o Panjang badan
:
o Lingkar kepala
:
o Lingkar dada
:
o Lingkar perut
:
o Lingkar lengan atas :
APGAR SKOR
No Tgl/Jam
Karakteristik
yang dinilai

10

Denyut jantung
Pernafasan
Refleks
Tonus otot
Warna kulit

Total Menit 1 :
Menit 5 :
Menit 10 :
Kesimpulan
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3. Kala III
Tanggal
Jam
Hasil observasi

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Nama klien

ANALISA DATA
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Umur
No
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Penyebab

Masalah

(Etiologi)

(Problem)

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Kala IV
Tanggal

Jam

Hasil Observasi
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Nama klien

ANALISA DATA
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Umur
No
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Penyebab

Masalah

(Etiologi)

(Problem)

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ASUHAN KEPERAWATAN
Tanggal

Jam

Diagnosa
keperawatan

Tujuan

Intervensi

Implementasi

Evaluasi