Lampiran B

KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS SAM RATULANGI
FAKULTAS KEDOKTERAN
PROGRAM STUDI ILMU KEPERAWATAN
KAMPUS UNSRAT KOTAK POS No. 333 MANADO 95115SULAWESI UTARA

PENGKAJIAN INTRANATAL
I. DATA UMUM
Inisial klien : ................ (.....th) Nama Suami : .............................(......th)
Pekerjaan : ............................... Pekerjaan : .............................................
Pendidikan Terakhir : ............................... Pendidikan terakhir :.............................
Agama : ........................... Agama : .............................................
Suku bangsa :. .....................
Status perkawinan : ......................................................
Alamat : .........................................................................................................
II. DATA UMUM KESEHATAN
TB/BB : ................cm/.................kg
BB sebelum hamil : .....................kg
Masalah kesehatan khusus : ...........................................................................
Obat-obatan : .................................................................................................
Alergi (obat/makanan/bahan tertentu) : .........................................................
Diet khusus : ..................................................................................................
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain-lain : .......................................................................................................
Frekuensi BAB/BAK:...................................................................................
Masalah BAB/BAK : ..............................................................................................
Kebiasaan waktu tidur : ..............................................................................................

III. DATA UMUM KEBIDANAN

Kehamilan sekarang direncanakan (ya/tidak)*
Status Obstetri : G ...........P.............A ............
HPHT : ................................. Taksiran partus :
................................................
 Jumlah anak di rumah : ..............................................
No Jenis Cara lahir BB Keadaan saat ini Umur
kelamin Lahir

Mengikuti kelas prenatal (ya/tidak) : ..............

Jumlah kunjungan ANC pada kehamilan ini : .......................................
Masalah kehamilan yang lalu :
....................................................................................
Masalah kehamilan sekarang :
.....................................................................................
Rencana KB : .............................
Makanan bayi sebelumnya : ASI/PASI/lainnya*
Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi,/pernafasan/manfaat ASI/cara memberi minum botol/senam nifas/metode
KB/perawatan perineum/perawatan payudara/lain-lain,
jelaskan ...........................................................................................................................
Setelah bayi lahir, siapa yang diharapkan membantu : .............................................
Masalah dalam persalinan yang lalu : ........................................................................

IV. RIWAYAT PERSALINAN SEKARANG

Mulai persalinan (kontraksi): tanggal/jam : ............................
Pengeluaran pervaginam (tanggal/jam) : ...............................
Keadaan kontraksi (frekuensi
:.....................................................................................
dalam10 menit, lamanya, kekuatannya)
Denyut jantung janin : Frekuensi ...................................
Kualitas : ...................................
Irama : .......................................
Pemeriksaan fisik :
Kenaikan BB selama hamil : .....................kg
 TTV : TD........... mmHg,N..... x/mnt S........ oC R......
x/mnt
Kepala dan leher :..................................................................................(normal/tidak)
Jantung : ......................................................................................................................
Paru-paru : ...................................................................................................................
Payudara : ...................................................................................................................
Abdomen : (secara umum dan pemeriksaan obstetrik) : ............................................
............................................................................................................................
......
Ekstremitas : edema/tidak ..........................................................................................
Refleks : ......................................................................................................................
Pemeriksaan dalam pertama : (jam) .......................oleh : ............................................
Hasil:.....................................
.....................................................................................
Ketuban : (utuh/pecah), jika sudah pecah : tgl/jam :...................................................
warna......................................................
Laboratorium : .............................................................................................................
..............................................................................................................

V. DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : ............................................................................
Perasaan klien terhadap kehamilan sekarang :.........................................................
...................................................................................................................
Perasaan suami terhadap kehamilan sekarang : ........................................................
Jelaskan respon sibling terhadap kehamilan sekarang : .............................................
LAPORAN PERSALINAN
I. Pengkajian awal
Tanggal : .........................Jam : ............................
TTV : TD......................mmHg,N.......................x/mnt S...............oC
R..............x/mnt
Pemeriksaan palpasi abdomen
Leopold I : ..............................................................................
Leopold II : . ..............................................................................
Leopold III : ..............................................................................
Leopold IV : ..............................................................................
Hasil pemeriksaan dalam : ...............................................................................
Pemeriksaan perineum : .........................................................................................
 Dilakukan klisma (ya/tidak) : .............
Pengeluaran pervaginam : ................................................................
Perdarahan pervaginam (ya/tidak) :.................
Kontraksi uterus (frekuensi, lamanya, kekuatan) : ................................................
DJJ : (frekuensi/kualitas)................................./.....................................................
Status janin : (hidup/tidak,jumlah,presentasi) : .....................................................
...............................................................................................................................
II. Kala persalinan
Kala I
Mulai persalinan : (tanggal/jam)............................................................................
Tanda dan gejala : .................................................................................................
Lama Kala I : (jam/menit/detik)............................................................................
Keadaan psikososial : ...........................................................................................
Kebutuhan khusus klien : .....................................................................................
Tindakan : ............................................................................................................
Pengobatan : .........................................................................................................
Observasi kemajuan persalinan :

Tanggal/jam Kontraksi DJJ Keterangan

uterus

Kala II
Kala II dimulai : (Tgl/jam) : ...................................................................................
TTV : TD..............mmHg,N......... x/mnt S...... oC R..............x/mnt
Lama kala II : (jam/menit/detik)
...................................................................................
Keadaan psikososial : ...................................................................................................
Kebutuhan khusus klien : .............................................................................................
Tindakan :
.................................................................................................................
Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur : ................................
Bonding ibu dan bayi :.......................
TTV bayi :TD......... mmHg,N....... x/mnt S....... oC R..... x/mnt
Pengobatan :
.................................................................................................................
Catatan kelahiran :
Bayi lahir jam : .......................................
Jenis kelamin : ........................................
Nilai APGAR menit I................................menit V...........................
BB/PB/lingkar kepala : .........................gram.........................cm....................cm
Karakteristik khusus bayi : ..........................................................................................
Kaput suksadaneum/cephal hematoma : ......................................................................
Anus : berlubang/tertutup*
Perawatan tali pusat :..............................................................
Perawatan mata : ...................................................................

Kala III
Mulai jam : .................
TTV : TD...........mmHg,N......... x/mnt S..... oC R......x/mnt
Tanda dan gejala :...........................................................................................................
Plasenta lahir jam : ........................................................................................................
Cara lahir plasenta :.........................................................................
Karakteristik plasenta :.....................................................................
Diameter : ..........cm
Ketebalan : .............cm
Panjang tali pusat : ..........................................................................
Jumlah pembuluh darah :.........................arteri .......................vena
Insersio tali pusat : ..........................................................................
Kelainan : ........................................................................................
Perdarahan : .........................ml
Karakteristik perdarahan : ...............................................................
Keadaan psikososial : ......................................................................
Kebutuhan khusus : .........................................................................
Tindakan : .......................................................................................
Pengobatan : ....................................................................................
Kala IV
Mulai jam : ................
TTV : TD........mmHg,N..... x/mnt S..... oC R..... x/mnt
Kontraksi uterus : ..........................................................................................................
Perdarahan :......................ml
Karakteristik : .............................................................................................................
Tindakan :.............................................................................................................
 LAPORAN PARTUS NORMAL
SYAIR OBSTETRI

Nama Klien :
Status Obstetri :

Tanggal / jam Keterangan

Lampiran C
KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI
UNIVERSITAS SAM RATULANGI
FAKULTAS KEDOKTERAN
PROGRAM STUDI ILMU KEPERAWATAN
KAMPUS UNSRAT KOTAK POS No. 333 MANADO 95115SULAWESI UTARA

FORMAT RESUME BAYI BARU LAHIR

Tanggal lahir bayi : ....................................... Tanggal pengkajian : ...............................

Proses Kelahiran bayi :

Perawatan bayi yang dilakukan :