FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
PENGKAJIAN INTRANATAL
I. IDENTITAS KLIEN
Nama klien : ……………………... Nama suami : ………………………
Umur : ……………………... Umur : ………………………
Suku/Bangsa : ……………………... Suku/Bangsa : ………………………
Pendidikan : ……………………... Pendidikan : ………………………
Pekerjaan : ……………………... Pekerjaan : ………………………
Agama : ……………………... Agama : ………………………
Penghasilan : ……………………... Penghasilan : ………………………
Gol Darah : ……………………... Gol Darah : ………………………
Alamat : ……………………... Alamat : ………………………
3. Auskultasi
DJJ : .......................................................................
Punctum maksimum : .......................................................................
Tempat : .......................................................................
Frekuensi : .......................................................................
Teratur atau tidak : .......................................................................
Peristaltik usus : .......................................................................
Kesimpulan :. ..................................................................
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g. Genetalia dan anus
Pengeluaran pervaginam : …………………………………………….
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Vulva, odem, lesi : ……………………………………………...
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Vagina Toucher : ……………………………………………...
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Ketuban sudah pecah : …………………………………….............
Anus dan perineum : ……………………………………………...
Score Bisop : ……………………………………..............
Kesimpulan : ……………………………………………...
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h. Punggung
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i. Ekstremitas
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j. Integumen
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k. Pemeriksaan laboratorium
Urine : …………………………………………………………………
Darah : …………………………………………………………………
Feses : ………………………………………………………………….
l. Terapi
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m. Pemeriksaan Diagnostik dan Penunjang Lain:
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Jember, 2018
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DAFTAR DIAGNOSA KEPERAWATAN
No Nama/ttd
Tanggal Tujuan & Kriteria Hasil Planning Rasional
Dx Mhs
TINDAKAN PERAWATAN
Nama/ttd
Tanggal Jam No Dx Tindakan Perawatan
Mahasiswa
EVALUASI
Nama/ttd
Tanggal Jam No Dx Evaluasi
Mahasiswa