PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA

PERIODE INTRANATAL

Nama Mahasiswa :
Nomor Mahasiswa :
Tanggal pengkajian : Februari 2018
Tempat Praktek : Ruang VK (ruang bersalin)
Tanggal Praktek : 16 Februari 2018 - 17 Februari 2018

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 : G….P….A….. Usia kehamilan………………...…….…
………………………………………………………………………………..
3. HPHT ……………………………. Tafsiran partus………………………….
………………………………………………………………………………..
4. Jumlah anak dirumah
……………………………………………………………………………….

Tempat Komplikasi
Jenis Cara persalinan BB selama Keadaan
No Umur
Kelamin lahir dan lahir proses saat ini
penolong persalinan

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)
a. Relaksasi pernafasan
b. Manfaat ASI dan cara menyusui yang baik
c. Senam nifas
d. Metode KB
e. Perawatan perineum
f. 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 (kontraksi / pengeluaran pervaginam): tanggal/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 selama kehamilan …………………………….kg
Tanda vital : TD = ……… mmHg ; Nadi = …..x /mnt ; suhu = ……C;
P= ……x/mnt
a. Kepala / leher
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b. Dada (jantung, paru-paru)
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c. Payudara
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d. Abdomen (secara umum dan pemeriksaan)
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 e. Kontraksi
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f. DJJ
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g. Ekstrimitas (edema / tidak)
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h. Refleks
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5. Pemeriksaan dalam
Jam pemeriksaan Oleh Hasil
........................... ................................. ..................................................
........................... ................................. ..................................................
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........................... ................................. ..................................................
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6. Ketuban (utuh / pecah)

Tidak, utuh
Ya, pecah
Tanggal/ jam: …………………………………………………………….
Warna : ……………………………………………………………..
7. Laboratorium
PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN METODA
HEMATOLOGI
Hemoglobin 12.50 – 16.70 g/dl Colorimetric
Leukosit 4.65 - 10.3 ribu/ul Impedance
Eritrosit 4.10 – 6.00 juta/ul Impedance
Hematokrit 42.00 - 52.00 vol% Analyze Calculates
Trombosit 150 – 356 ribu/ul Impedance
RDW-CV 12.1 - 14.0 % Analyze Calculates
MCV, MCH, MCHC
MCV 75.0 - 96.0 fl Analyze Calculates
MCH 28.0 - 32.0 pg Analyze Calculates
MCHC 33.0 – 37.0 % Analyze Calculates
HITUNG JENIS
Gran% 50.0 – 70.0 % Impedance
Limfosit% 25.0 – 40.0 % Impedance
MID% 4.0 – 11.0 % Impedance
Gran# 2.50 – 7.00 ribu/ul Impedance
Limfosit# 1.25 – 4.0 ribu/ul Impedance
MID# ribu/ul Impedance
PROTHROMBIN TIME
Hasil PT 9.9 – 13.5 Detik Nephelometri
INR - Nephelometri
Control Normal PT - - Nephelometri
Hasil APTT 22.2 – 37.0 Detik Nephelometri
Control Normal
- Nephelometri
APTT
KIMIA
GULA DARAH
Gula darah sewaktu <200 mg/dl GOD-PAP
URINALISA
Warna Kekeruhan Kuning-jernih Urinalysis Strips
BJ 1.005 – 1.030 Urinalysis Strips
pH 5.0 – 6.5 Urinalysis Strips
Keton Negative Urinalysis Strips
Protein-Albumin Negative Urinalysis Strips
Glukosa Negative Urinalysis Strips
Bilirubin Negative Urinalysis Strips
Darah Samar Negative Urinalysis Strips
Nitrit Negatif Urinalysis Strips
Urobilinogen 0.1 – 1.0 Urinalysis Strips
Leukosit Negative Urinalysis Strips
URINALISA (SEDIMEN)
Leukosit 0–3 Manual Mikroskop
Eritrosit 0–2 Manual Mikroskop
Selinder Negative Manual Mikroskop
Epithel 1+ Manual Mikroskop
Bakteri Negative Manual Mikroskop
Kristal Negative Manual Mikroskop
Lain-lain Negative Manual Mikroskop
FAAL LEMAK DAN JANTUNG
CKMB 0 - 24 U/L Optimised (C)
HATI
SGOT 0 - 46 U/I IFCC
SGPT 0 - 45 U/I IFCC
Albumin 3.5 – 5.5
GINJAL
Ureum 10 – 50 mg/dl Moodif-Berhelot
Creatinin 0.7 – 1.4 mg/dl Jaffe
ELEKTROLIT
Natrium 135 – 146 mmol/I ISE
Kalium 3.4 – 5.4 mmol/I ISE
Chlorida 95 – 100 mmol/I ISE

8. Terapi yang diberikan

Tanggal Jenis terapi Rute Dosis Indikasi terapi

terapi
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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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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 RENCANA ASUHAN KEPERAWATAN
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Kala II
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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 RENCANA ASUHAN KEPERAWATAN
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Keadaan Umum bayi baru lahir
Berat badan :
Panjang badan :
Lingkar kepala :
Lingkar dada :
Lingkar perut :
Lingkar lengan atas :
APGAR SKOR
Karakteristik yang
No Tgl/Jam 1 5 10
dinilai

Denyut jantung

Pernafasan

Refleks

Tonus otot

Warna kulit

Total Menit 1 :
Menit 5 :
Menit 10 :
Kesimpulan :
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Kala III
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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 RENCANA ASUHAN KEPERAWATAN
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Kala IV
Tanggal Jam Hasil Observasi
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 ANALISA DATA
Nama klien : ......................................................................................................
Umur : ......................................................................................................

Penyebab Masalah
No. Data (Symptom)
(Etiologi) (Problem)

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 RENCANA ASUHAN KEPERAWATAN
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan
Tgl/ Diagnosa
Tujuan Intervensi Implementasi Evaluasi TT
Jam Keperawatan