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PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER

PENGKAJIAN INTRANATAL

Rumah sakit : RSD dr. Soebandi Jember


Ruangan : ……………………………………………………………..
Tgl/ jam MRS : ……………………………………………………………..
Dx. Medis : ……………………………………………………………..
No. Register : ……………………………………………………………..
Yang merujuk : ……………………………………………………………..
Pengkajian oleh : ……………………………………………………………..
Tgl/jam Pengkajian : ……………………………………………………………..

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 : ………………………

II. RIWAYAT KESEHATAN


1. Kaluhan Utama:
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2. Riwayat Penyakit sekarang
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3. Riwayat penyakit dahulu
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4. Riwayat kesehatan keluarga
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5. Riwayat psikososial
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6. Pola fungsi kesehatan
a. Pola persepsi dan tata laksana hidup sehat
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b. Pola nutrisi dan metabolisme
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c. Pola aktivitas
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d. Pola eleminasi
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e. Pola persepsi sensori
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f. Pola konsep diri
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g. Pola hubungan dan peran
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h. Pola reproduksi dan seksual
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i. Pola penanggulangan stress/ koping
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7. Riwayat pengkajian obstetri, prenatal dan intranatal
a. Riwayat penggunaan kontrasepsi
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b. Riwayat menstruasi
Menarche : ……………………………………………………………..
Lamanya : ……………………………………………………………...
Siklus : …………………………………………………………………
Hari pertama haid terakhir : …………………………………………...
Tafsiran persalinan : …………………………………………………...
Disminorhe : …………………………………………………………...
Fluor albus :
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c. Riwayat kehamilan terdahulu :
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d. Riwayat kehamilan sekarang
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e. Riwayat persalinan lalu :
Data Ibu Data Anak
Hamil Tgl/bln/Th Tempat Usia Jenis Penolong Keadaan
Penyulit JK BB
Partus Partus Kehamilan Persalinan persalinan anak

Kehamilan direncanakan atau tidak :


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Komplikasi selama kehamilan :
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Komplikasi selama nifas :
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Spontan pervaginam : ..........................................................
Forcep : ..........................................................
Vakum : ..........................................................
Oksitosin drip : ..........................................................
Sectio secaria : ..........................................................
Pengobatan selama kehamilan : ..........................................................
Persalinan : ..........................................................
Nifas : ..........................................................
Alasan diberi pengobatan : ..........................................................
Riwayat ANC : ..........................................................
Tempat : ..........................................................
Pemeriksa : ..........................................................
Keteraturan : ..........................................................
Imunisasi : ..........................................................
8. Pemeriksaan fisik
a. Keadaan umum: .....................................................................................
b. Tanda-tanda vital dan atropometri:
 Suhu tubuh : ..................................................................................
 Nadi : ..................................................................................
 Tekana darah : ..................................................................................
 Respirasi : ..................................................................................
 TB/BB : cm / kg
 BB sebelum hamil : kg
 IMT : ...............................................................................................
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 Peningkatan BB : kg
c. Kepala & leher
 Kepala
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 Telinga
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 Mata
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 Hidung
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 Mulut
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 Leher
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d. Thorax / Dada
 Jantung
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 Paru-paru
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e. Pemeriksaan payudara
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f. Abdomen
Inspeksi
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1. Palpasi
Leopold I : .......................................................................
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Leopold II : .......................................................................
Leopold III : .......................................................................
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Leopold IV : .......................................................................
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Panjang TFU-simfisis : cm
TBJ : .............................................................................................
Merasakan gerakan janin : ..........................................................
His : ..........................................................
Adanya Braxton hicks : ..........................................................
Frekuensi his : ..........................................................
Kekuatan : ..........................................................
Lama relaksasi : ..........................................................

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

(Nikmatul Khoiriyah, S.Kep)


NIM 122311101075
ANALISA DATA

Tanggal No Data Fokus Problem Etiologi Nama


Terang
Mahasiswa

\
DAFTAR DIAGNOSA KEPERAWATAN

Tanggal No DIAGNOSA KEPERAWATAN Nama Terang & Tanda


Muncul Dx Tangan Mahasiswa
RENCANA TINDAKAN 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