FORMAT PENGKAJIAN INTRA NATAL

MATA AJAR KEPERAWATAN REPRODUKSI

PROGRAM STUDI NERS
STIKES MUHAMMADIYAH SAMARINDA
JL. Ir. H.Juanda No. 15 telp : (0541)748511 SAMARINDA

Nama Mahasiswa :
NIM : ........................................................................
Tanggal Pengkajian :
Rumah Sakit/ Ruang :......................................................................................

I. DATA UMUM KLIEN

1. Initial Klien : ..
2. Usia : ..
3. Status Perkawinan : ...
4. Pernikahan Ke :...............................................................................
5. Lama perkawinan : .....................................................................................
6. Pekerjaan : .
7. Pendidikan Terakhir : .
8. Inisial Suami :.
9. Usia :.
10. Pendidikan :....................................................................................
11. Pekerjaan (Spesifik) : .................................................................................
12. Suku/ Bangsa :
13. Pernikahan ke : .................................................................................
14. Alamat :

II. DATA UMUM KESEHATAN

1. TB/ BB : ......cm/.......kg
2. BB sebelum hamil : .................Kg
3. Masalah Kesehatan Khusus:

4. Obat-obatan yang diterima saat ini:

1
 5. Alergi (obat/ makanan/ bahan tertentu):
6. Diet Khusus :
7. Alat bantu yang digunakan:
Gigi palsu :
Kaca mata/ lensa kontak :
Alat dengar :
Lain-lain :
8. Frekuensi BAK: ................. masalah: ...............................................................
Frekuensi BAK menjelang persalinan: .................................
9. Frekuensi BAB, ........................................masalah:................................................
Frekuensi BAB menjelang persalinan: ..........................................................
10. Kebiasaan waktu tidur:
Kebiasaan tidur menjelang persalinan

III. DATA UMUM OBSTETRI

1. Kehamilan sekarang direncanakan: ya / tidak

Alasannya:
2. Status Obstetrik : G .....P......A......H.......minggu
3. HPHT: ........................................TP: ..............................
4. Jumlah anak:

No Jenis Cara Lahir BB L Keadaan Umur

Kelamin

5. Mengikuti kelas prenatal: ya/ tidak

6. Jumlah kunjungan ANC pada kehamilan ini:
Hambatan dalam ANC:
7. Masalah kehamilan yang dulu
8. Masalah kehamilan sekarang;
Upaya yang dilakukan untuk mengatasi:
9. Rencana KB setelah persalinan:
10. Makanan bayi sebelumnya:
- ASI : ya/ tidak , berapa lama:
- PASI: ya/ tidak, sejak usia bayi:

2
 11. Pelajaran bayi yang diinginkan saat ini:
- Relaksasi/ pernafasan:
- Managemen nyeri non farmakologi:
- Manfaat ASI
- IMD
- Metode KB
- Perawatan perineum
- Perawatan payudara
- Perawatan BBL
- Lain-lain: jelaskan:
12. Setelah bayi lahir, siapa yang diinginkan untuk membantu merawata bayi: suami/
orang tua/ mertua/ teman/ tenaga kesehatan
Alasan:
13. Masalah dalam persalinan sebelumnya

IV. RIWAYAT PERSALINAN SEKARANG

14. Mulai persalinan (kontraksi/ pengeluaran pervaginam)

Tgl/jam:
15. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan):
16. Frekuensi, kualitas dan keteraturan DJJ:
17. Pemeriksaan Fisik:
- Kenaikan BB selama kehamilan: ........................kg
- Tanda Vital: TD:............mmHg; N:........x/mnt; RR:...........x/mnt; suhu: ....... oC
- Kepala dan leher:
a. Bentuk :
b. Konjungtiva :-------------------------------------
c. Sklera : ------------------------------------
d. Edema palpebra :-------------------------------------
e. Pandangan kabur :-------------------------------------
f. Pupil :-------------------------------------
g. Pembesaran kelenjar tyroid :-------------------------------------
h. Pembesaran kelenjar getah bening :-------------------------------------
i. Kesulitan menelan :------------------------------------
j. Keluhan lain :-----------------------------------
- Dada dan axilla
a. Mammae : membesar :ya/ tidak
b. Perubahan kontour kulit pd payudara :-------------------------------------
c. Areolla mamae : .
d. ASI/Nanah/Darah :..
e. Pembesaran KGB di axila :---------------------------------------
f. Sesak nafas :--------------------------------------
g. Retraksi dinding dada :---------------------------------------

- Abdomen
3
 a. Tinggi Fundus Uteri :
b. Lingkar abdomen :--------------cm
c. Linea dan striae :.
d. Hiperpigmentasi :--------------------------------------
e. Luka bekas operasi / jenis :/.
f. Kontraksi :.
g. Teraba massa: ya/tidak, jika ya di daerah:------------------------------
h. Distensi abdomen :-------------------------------------
i. Bising Usus :-------------------------------------
j. Lainnya sebutkan :.
- Genitourinary
a. Area genital bersih :----------------------------------------
b. Ada discharge : ya / tidak; jenis :----------------------------------------
c. Ada perdarahan antara fase menstruasi :---------------------------------------
d. Perdarahan pasca coitus :------------------------------------------
e. Vesika urinary penuh :.
f. Rangsang miksi menurun :---------------------------------------
g. Nyeri saat miksi :---------------------------------------
h. Miksi tidak tuntas :---------------------------------------
i. Lainnya, sebutkan :
-
18. Pemeriksaan dalam pertama:
- Jam : .............................................oleh:.......................................
- Hasil:
o Pembukaan:
o Ketuban :
o Serviks
o Molase
19. Laboratorium

20. CTG: Pukul: .....................................kesan:

V. DATA PSIKOSOSIAL dan EKONOMI

1. Penghasilan keluarga setiap bulan:

2. Respon klien terhadap kehamilan sekarang:
3. Respon pasangan terhadap kehamilan sekarang

4
 4. Respon sibling terhadap kehamilan sekarang:
5. Cara pasangan mengenalkan calon adik baru:
6. Ketertarikan pasangan selama kehamilan:
7. Pantangan selama kehamilan:
8. Kebudayaan yang dianut:

LAPORAN PERSALINAN

I. PENGKAJIAN AWAL
1. Tanggal:.......................................jam:....................................

5
 2. Tanda-tanda vital: TD:...................mmHg, Nadi:.................x/mnt; Suhu:......... o C,
P:.........x/mnt
3. Pemeriksaan palpasi
abdomen:...................................................................................................
4. Hasil periksa
dalam:..........................................................................................................................
5. Persiapan
perineum:.........................................................................................................................
6. Klisma : ya /tidak,
jelaskan:...........................................................................................................
7. Pengeluaran
pervaginam:................................................................................................................
8. Perdarahan pervaginam: ya/ tidak
jelaskan............................................................................
9. Kontraksi uterus: (frekuensi, durasi,
kekuatan):..................................................................
10. DJJ:.............x/mnt, teratur: ya/ tidak
11. Status janin: (hidup/tidak; jumlah:......................presentasi:................................)

II. KALA PERSALINAN

Kala I
1. Mulai persalinan: tanggal:....................pukul:.............................
2. Tanda dan
gejala:..........................................................................................................................................
........................................................................................................................................................
3. Tanda-tanda vital: TD:...............mmHg; Nadi:..................x/mnt; Suhu:.......... oC;
P:..........x/mnt
4. Lama Kala I:
5. Kondisi psikososial: ..............................................................................................................
........................................................................................................................................................
........................................................................................................................................................
6. Kebutuhan khusus
klien:.....................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
7. Diagnosa Keperawatan: ......................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
8. Tindakan:...................................................................................................................................
..
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

9. Pengobatan yang
didapat:....................................................................................................

6
 ........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
..........................
10. Observasi kemajuan persalinan
Tgl/jam Kontraksi uterus DJJ Keterangan

7
8
9
 Kala II

1. Kala II dimulai :
Hari/Tanggal :.......................................Jam:..............................
2. Tanda-tanda vital:
TD: .......................mmHg, Nadi: ....................x/mnt, Suhu:.................oC,
P:................x/mnt
3. Lama Kala II: .............jam................menit
4. Tanda dan gejala............................................................................................................................
...............................................................................................................................................................
5. Jelaskan upaya meneran:...........................................................................................................
...............................................................................................................................................................
6. Keadaan psikososial:....................................................................................................................
...............................................................................................................................................................
7. Kebutuhan khusus: ......................................................................................................................
...............................................................................................................................................................
8. Diagnosa Keperawatan:
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
....................
9. Tindakan: .........................................................................................................................................
.......
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
................................................

Catatan Kelahiran
1. Bayi lahir
jam: .................................................................................................................................
2. Bugar: Ya/ Tidak
3. APGAR Score menit I..................menit ke V: ..........................
4. Perineum (utuh/episiotomi/ruptur), jika ruptur
tingka...........................................
5. Bonding ibu dan
bayi..................................................................................................................
6. Tanda-tanda vital: Nadi:..............x/mnt, RR:............x/mnt, suhu: ..............oC
7. Diagnosa
Keperawatan:........................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...................
8. Tindakan: ..................................................................................................................................
.......

10
 ........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...........................
9. Pengobatan: .............................................................................................................................
.......
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...................

Kala III:
1. Tanda dan gejala: .....................................................................................................................
...........................................................................................................................................................
.........................................................................................................................................................
2. Plasenta lahir jam :...................................................................................................................
3. Cara lahir plasenta: ................................................................................................................
4. Karakteristik Placenta: Ukuran ............cm x .............cm x ................cm
Panjang tali pusat : .........cm
Jumlah pembuluh darah .....................arteri, ..............vena
Selaput ketuban: ......................................................................................................................
Kelainan:......................................................................................................................................
5. Perdarahan : ........ml, karakteristik :.................................................................................
6. Keadaan psikososial : .............................................................................................................
..........................................................................................................................................................
7. Kebutuhan khusus:..................................................................................................................
..........................................................................................................................................................
8. Diagnosa Keperawatan : ......................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
9. Tindakan: ....................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
10. Pengobatan: ............................................................................................................................
...............................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

Kala IV
1. Mulai jam .....................................................................................................................................
2. Tanda-tanda vital
TD: .......................mmHg, Nadi: ....................x/mnt, Suhu:.................oC,
P:................x/mnt
3. Kontraksi uterus:.....................................................................................................................
4. Perdarahan : ........ml, karakteristik :.................................................................................
5. Keadaan psikososial : ............................................................................................................
..........................................................................................................................................................
11
 7.Bonding Ibu dan Bayi : ...........................................................................................................
8. Kebutuhan khusus:..................................................................................................................
..........................................................................................................................................................
9. Diagnosa Keperawatan : ......................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
10. Tindakan:...................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...........................
11. Pengobatan: .........................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..................

Bayi
1. Bayi lahir tanggal/ jam : .......................
2. Jenis Kelamin: ...........................................
3. Niali Apgar : I .............................V: .............................
4. PB/ BB/Lingkar kepala: ............cm/ .............. gram/..............cm
5. Karakteristik khusus bayi :..................................................................................................
6. Caput: Suksedanum / cephallhematum
7. Suhu : ...........oC
8. Anus : berlubang / tertutup
9. Perawatan tali pusat : ............................................................................................................
10. Perawatan Mata: ...................................................................................................................
11. Imunisasi Hepatitis I: ya/ tidak, di .,..............................................................................
Pemberian Vitamin K : ya/ tidak, di ...............................................................................
12. Kebutuhan khusus:................................................................................................................
..........................................................................................................................................................
13. Diagnosa Keperawatan : ...................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
14. Tindakan:..................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
..........................................................................................................................................
15. Pengobatan: ............................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

12