ASUHAN KEPERAWATAN INTRANATAL PADA ______

DI RUANG BERSALIN RSUD KARANGANYAR

Di Susun Untuk Memenuhi Tugas

Stase Keperawatan Maternitas

Di Susun Oleh:
EKO BUDIARTO
NIM : 2016131022

PROGRAM PROFESI NERS

FAKULTAS ILMU KESEHATAN
UNIVERSITAS SAHID SURAKARTA
TAHUN 2017
PENGKAJIAN INTRANATAL

Nama Mahasiswa : .................................................. NPM : ..........................

Tempat Praktik : .................................................. TGL : ..........................

I. DATA UMUM
Inisial klien : .......................................................................................
Umur : .......................................................................................
Agama : .......................................................................................
Suku Bangsa : .......................................................................................
Penidikan terakhir : .......................................................................................
Status pernikahan : .......................................................................................
Nama Suami : .......................................................................................
Umur Suami : .......................................................................................
Pekerjaan Suami : .......................................................................................

II. DATA UMUM KESEHATAN

1. TB/BB : ...........................................................................
2. BB Sebelum Hamil : ...........................................................................
3. Masalah Kesehatan
Khusus : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
4. Obat-obatan : ...........................................................................
5. Alergi : ...........................................................................
6. Eliminasi BAK : ...........................................................................
7. Elimiminasi BAB : ...........................................................................
8. Pola Tidur : ...........................................................................
III. DATA UMUM KEBIDANAN

1. Kehamilan sekarang
direncanakan : Ya / Tidak
2. Status Obstetri : G .... P .... A ....
3. HPHT : ...........................................................................
4. Jumlah anak dirumah
No Jenis Cara BB Keadaan Umur
1
2
3
4
5

5. Mengikuti kelas perinatal : ...............................................................

6. Jumlah kunjungan
pada kehamilan ini : ...............................................................
7. Masalah kehamilan sebelumnya : ...............................................................
...............................................................
8. Masalah persalinan sebelumnya : ...............................................................
...............................................................
9. Masalah kehamilan sekarang : ...............................................................
10. Riwayat KB : ...............................................................
11. Makanan bayi sebelumnya : ...............................................................
12. Pelajaran apa yang diinginkan
saat ini : ...............................................................
13. Setelah lahir siapa yang di -
harapkan membantu : ...............................................................

IV. RIWAYAT PERSALINAN SEKARANG

a. Mulai persalinan
(kontraksi/pengeluaran pervaginam) : ...................................................
b. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan)
No Kontraksi Uterus Frekuensi Lamanya Kekuatan
c. Frekuensi dan kualitas DJJ : ...................................................

d. Pemeriksaan fisik
Kenaikan BB selama hamil : ...............................................................
Tanda-tanda vital
TD : .................................. Nadi : ..................................
Nadi : .................................. Suhu : ..................................
Kepala dan Leher : ...........................................................................
Jantung : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
Payudara : ...........................................................................
...........................................................................
...........................................................................
Abdomen : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
DJJ : ...........................................................................
Ekstremitas : ...........................................................................
e. Pemeriksaan penunjang
PEMERIKSAAN HASIL NILAI SATUAN
RUJUKAN
HEMATOLOGI
Hemoglobin
Hematokrit
Lekosit
Trombosit
Eritrosit
MPV
PDW
INDEX
MCV
MCH
MCHC
HITUNG JENIS
Gran%
Limfosit%
Monosit%
Eosinofil%
Golongan darah :
HBSAg :
Anti HIV :

f. Terapi Medis
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
 LAPORAN PERSALINAN

I. PENGKAJIAN AWAL

1. Tanggal/Jam : .......................................................................................
2. Tanda-tanda vital
TD : ...............................
Nadi : ...............................
RR : ...............................
Suhu : ...............................
3. Pemeriksaan palpasi
abdomen : .......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
4. Hasil periksa dalam : ...................................................
5. Persiapan perineum : ...................................................
6. Dilakukan klisma : ...................................................
7. Pengeluaran pervaginam : ...................................................
8. Perdarahan pervaginam : ...................................................
9. Denyut Jantung Janin : ...................................................
10. Status Janin : ...................................................

II. KALA PERSALINAN

KALA I
1. Mulai kala I tanggal : ............................. Jam : ...............................
2. Lama kala I : ...........................................................................
3. Tanda dan gejala : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
4. Hasil pemeriksaan : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
5. Keadaan psikososial : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
6. Kebutuhan khusus ibu : ...........................................................................
...........................................................................
7. Tindakan : ...........................................................................
8. Pengobatan : ...........................................................................
...........................................................................

Jam Kontraksi Uterus Kekuatan

KALA II
1. Mulai tanggal : ................................. Jam: ............................................
2. Lama kala II : ...........................................................................
3. Tanda dan gejala : ...........................................................................
............................................................................
4. Penjelasan upaya
Meneran : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
5. Keadaan psikososial : ...........................................................................
6. Tindakan : ...........................................................................
...........................................................................
...........................................................................
Kala III
1. Tanda dan gejala : ...........................................................................
...........................................................................
...........................................................................
2. Tindakan : ...........................................................................
3. Plasenta lahir jam : ...........................................................................
4. Cara lahir plasenta : ...........................................................................
5. Karakteristik plasenta : ...........................................................................
6. Panjang tali pusat : ...........................................................................
7. Pembuluh darah : ...........................................................................
8. Kelainan : ...........................................................................
9. Perdarahan : ...........................................................................
10. Keadaan psikososial
Ibu : ...........................................................................
...........................................................................
11. Kebutuhan khusus ibu : ...........................................................................
12. Tindakan : ...........................................................................
13. Pengobatan : ...........................................................................

KALA IV
a. Mulai jam : .......................................................................................
b. TTV : suhu ........., TD ........... mmgh, nadi .......... x/menit
RR .......... x/menit
c. Keadaan uterus : ...........................................................................
d. Perdarahan : ...........................................................................
e. Bonding ibu dan bayi : ...........................................................................
f. Tindakan : ...........................................................................
...........................................................................
...........................................................................
g. Pengobatan : ...........................................................................

BAYI
a. Bayi lahir tanggal/jam : ...........................................................................
b. Jenis kelamin : ...........................................................................
c. Nilai ABGAR
ABGAR SCORE Menit 1 Menit 5 Menit 10
Jantung
Nafas
Otak
Rangsang
Warna
Jumlah

d. BB/PB bayi : ...........................................................................

e. Karakteristik bayi : ...........................................................................
...........................................................................
f. Lingkar kepala : ...........................................................................
g. Kaput suksedaneum : ...........................................................................
h. Suhu : ...........................................................................
i. Anus : ...........................................................................
j. Perawatan tali pusat : ...........................................................................
k. Perawatan mata : ...........................................................................
 ANALISA DATA

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................
Diagnosa Medis : .................................................. Tanggal : ..................................................

NO DATA DIAGNOSA KEPERAWATAN TTD

 RENCANA KEPERAWATAN

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................

NO DIAGNOSA KEPERAWATAN TUJUAN DAN KH INTERVENSI RASIONAL

NO DIAGNOSA KEPERAWATAN TUJUAN DAN KH INTERVENSI RASIONAL
 CATATAN KEPERAWATAN

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................

NO
TANGGAL IMPLEMENTASI EVALUASI TTD
DX
NO
TANGGAL IMPLEMENTASI EVALUASI TTD
DX