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

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

c. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke
N
o

Kehamilan
Umur

Tahun

Kehamila
n

Persalinan

Komplikasi Nifas

Penyuli

Jeni

Penolon

Penyuli

Laseras

Infeks

Anak
Jenis

Perdarahan

Kelami
n

d. Riwayat kehamilan saat ini :

Status obstetrikus :

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

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

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

kehamilan sekarang)

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

e. Riwayat Keluarga Berencana :

Akseptor KB

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

Masalah

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

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

B
B

Pj

f. Riwayat Penyakit Klien dan Keluarga

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.................................................................................................................................
.................................................................................................................................
...............
IV.

POLA FUNGSIONAL KESEHATAN

a. Pemeliharaan dan persepsi terhadap kesehatan
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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
0
1
2
3
4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alatbantu, 2: dibantu orang lain, 3: dibantu orang lain danalat,
4: tergantung total
Keterangan :

e. Pola tidur dan istirahat

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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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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

: ..

Penurunankepala

(penurunanbagianterbawahdenganmetode 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. Lampirkan Pantograf
VII.

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 KEPERAWATANKALA I

NO

DIAGNOSA

RENCANA KEPERAWATAN
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASIKALA I
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGANKALA I
N

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI

O
S:

O:

PARAF

A:

P:

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

NO

DIAGNOSA

RENCANA KEPERAWATAN
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASI KALA II
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGANKALA II
N

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI

PARAF

O
S:

O:

A:

P:

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

NO

DIAGNOSA

RENCANA KEPERAWATAN
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASIKALA III
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGANKALA III

N

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI

O
S:

O:

A:

P:

PARAF

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

B. ANALISA DATA KALA IV

DATA OBEKTIF

DATA

ETIOLOGI

MASALAH

Diagnosa keperawatan berdasarkan prioritas :

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

C. RENCANA KEPERAWATAN KALA IV

NO

DIAGNOSA

RENCANA KEPERAWATAN
TUJUAN

INTERVENSI

RASIONAL

D. IMPLEMENTASIKALA IV
TANGGAL/JAM

NO. DX

IMPLEMENTASI

RESPON KLIEN/ EVALUASI

PARAF
NAMA

E. EVALUASI/CATATAN PERKEMBANGANKALA IV
N

TANGGAL/ JAM

NO DIAGNOSA

EVALUASI

O
S:

O:

A:

P:

PARAF

Mengetahui,
Pembimbing klinik/CI
Mahasiswa

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

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

NIP.

NIM.
Clinical Teacher/ CT

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