FORMAT ASUHAN KEPERAWATAN INTRANATAL

ASUHAN KEPERAWATAN PADA Ny…………………

DENGAN……………………………………...................
DI RUANG …………………………………...................
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TANGGAL ………………….......................................

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :
Umur :
Pendidikan :
Pekerjaan :
Status Perkawinan :
Agama :
Suku :
Alamat :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
Penanggung Jawab
Nama :
Umur :
Pendidikan :
Jenis kelamin :
Pekerjaan :
Alamat :
Status perkawinan :
Agama :
B. DATA KESEHATAN
a. Keluhan Utama :

b. Keluhan saat dikaji :

c. Riwayat keluhan (kaji data mulai dari timbulnya keluhan sampai dengan
dilakukan asuhan keperawatan)
RIWAYAT OBSTETRI DAN GINEKOLOGI
1.Riwayat Menstruarsi :
 Menarche : umur ….. Siklus : teratur ( ) tidak ( )
 Banyaknya :…. Lama :………
 Keluhan :………
 HPHT :………..

2.Riwayat pernikahan
 Menikah : ….kali Lama : ….tahun

b. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak Kehamilan Persalinan Komplikasi nifas Anak
Ke
N Th Umur Peny jen penol Peny Laser infe Perdara Jenis B P
o n kehami ulit is ong ulit asi ksi han Kela B j
lan min

c. Riwayat kehamilan saat ini

Status Obstetrikus :
 G…P…A…H… UK : ……..minggu
 TP : ….
  ANC kehamilan sekarang :………...........................................
Trimester I :…………………………………………………………
Trimester II : …………………………………………………….....
Trimester III : ……………………………………………………....

d. Riwayat keluarga berencana

 Akseptor KB : …...
 Jenis : ……
 Lama : ………
 Masalah : ……

D. RIWAYAT PENYAKIT
1. Klien :…………
2. Keluarga : …………

E. POLA FUNGSIONAL KESEHATAN

1. Pola Manajemen Kesehatan-Persepsi Kesehatan
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2. Pola Metabolik-Nutrisi
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3. Pola Eleminasi
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4. Pola Aktivitas-Latihan
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5. Pola Istirahat-Tidur
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6. Pola Persepsi-Kognitif
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7. Pola Konsep Diri-Persepsi Diri

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8. Pola Hubungan-Peran
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9. Pola Reproduktif-Seksualitas
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10. Pola Toleransi Terhadap Stres-Koping

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11. Pola Keyakinan-Nilai

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F.PEMERIKSAAN FISIK
Keadaan umum :
 GCS : E..…….....….V.....................M...................
 Tingkat kesadaran : ………………….........................................
 Tanda – tanda vital : TD….............N….........RR….........T…......
 BB : ………….TB:………… LILA :………..

Head toe toe :

 Kepala
wajah :
Pucat ( )
Cloasma ( )
sklera :
konjungtiva :
pembesaran limphe node
pembesaran kelenjar tiroid :
telinga : ………………………………………
 Dada
Payudara
 Areola :……………..
Putting : (menonjol / tidak )
Tanda dimpling / retraksi :…………………
Pengeluaran ASI : ………………..
Jantung : ……….
Paru : …………..
 Abdomen
Linea : ……
Striae :…………
Pembesaran sesuai UK : ………….
Gerakan Janin : …………..
Kontraksi : …….
Luka bekas operasi : …………..

Ballottement : ……………………….
Leopold I : Kepala / bokong / kosong TFU:…….............
Leopold II : Kanan : punggung/bagian kecil/bokong /kepala
Kiri : punggung / bagian kecil /bokong/kepala
Leopold III : Presentasi kepala / bokong/kosong
Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar)
Penurunan kepala : .........(penurunan bag.terbawah dengan metode lima
jari )
Kontraksi : ………………….
DJJ :…………………..
Bising usus : …………………..

 Genetalia dan perineum :

Kebersihan :……………
Pengeluaran :………………….
Karakteristik :……………..
Hasil VT : ……………………………………………………………….
 Hemoroid :…………………
 Ekstremitas
Atas
Oedema :………………....................................................…
Varises :…………………....................................................
CRT :…………………....................................................
Bawah
Oedema :…………………....................................................
Varises :…………………....................................................
CRT :…………………....................................................
Refleks :……………….......................................................

G.DATA PENUNJANG
 Pemeriksaan Laboratorium :………………………..
 Pemeriksaan USG :………………………..

H.DIAGNOSA MEDIS

I.PENGOBATAN
II. ANALISA DATA KALA I
DATA FOKUS ANALISIS MASALAH
 Diagnosa keperawatan berdasarkan prioritas :

I. RENCANA KEPERAWATAN KALA I

I. RENCANA KEPERAWATAN
Diagnosa Tujuan Intervensi Rasional
keperawatan
IV. IMPLEMENTASI KALA I
Tgl/Jam No. Implementasi Evaluasi Paraf/Nama
Dx
V.EVALUASI KALA I

Tgl/Jam No. Evaluasi Paraf

Dx
KALA II

A. ANALISA DATA KALA II

DATA FOKUS ANALISIS MASALAH
 Diagnosa keperawatan berdasarkan prioritas :

B. RENCANA KEPERAWATAN KALA II

Diagnosa Tujuan Intervensi Rasional
keperawatan
 C. IMPLEMENTASI KALA II

Tgl/Jam No. Implementasi Evaluasi Paraf/Nama

Dx
D. EVALUASI KALA II

Tgl/Jam No. Evaluasi Paraf

Dx
KALA III
E. ANALISA DATA KALA III
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :

F. RENCANA KEPERAWATAN KALA III

Diagnosa Tujuan dan Kriteria
Intervensi Rasional
Keperawatan Hasil
 G. IMPLEMENTASI KALA III
Tgl/Jam No. Implementasi Evaluasi Paraf/Nama
Dx
H. EVALUASI KALA III

No.
Tgl/Jam Evaluasi Paraf
Dx
KALA IV
A. ANALISA DATA KALA IV
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
 B. RENCANA KEPERAWATAN KALA IV
Diagnosa Tujuan Intervensi Rasional
keperawatan
D. IMPLEMENTASI KALA IV
Tgl/Jam No. Implementasi Evaluasi Paraf/Nama
Dx
A. EVALUASI KALA IV
Tgl/Jam No. Evaluasi Paraf
Dx
Denpasar, …………………….20…..