“ INTRANATAL “
I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ..................................................................................................
Umur : ..................................................................................................
Pendidikan : ..................................................................................................
Pekerjaan : ..................................................................................................
Status Perkawinan : ..................................................................................................
Agama : ..................................................................................................
Suku : ..................................................................................................
Alamat : ..................................................................................................
No CM : ..................................................................................................
Tanggal MRS : ..................................................................................................
TanggalPengkajian : ..................................................................................................
Sumberinformasi : ..................................................................................................
PENANGGUNG JAWAB
Nama : ..................................................................................................
Umur : ..................................................................................................
Pendidikan : ..................................................................................................
JenisKelamin : ...................................................................................................
Pekerjaan : ...................................................................................................
Alamat : ...................................................................................................
Status Perkawinan : ...................................................................................................
Agama : ...................................................................................................
B. DATA KESEHATAN
1. KeluhanUtama
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2. Keluhansaatdikaji
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3. Riwayatkeluhan
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Komplikasinifas Anak
Laserasi infeksi Perdarahan JenisKelamin BB Pj
4. Riwayatkehamilansekarang
Status Obstetrikus :
G….. P….. A…... H…..
UK : ………. minggu
TP : ………..
ANC kehamilansekarang
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Trimester I : .....................................................................................................
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Trimester II : .....................................................................................................
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Trimester III : .....................................................................................................
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5. Riwayatkeluargaberencana
Akseptor KB : ..................................................................................................
Jenis : ..................................................................................................
Lama : ..................................................................................................
Masalah : ..................................................................................................
D. RIWAYAT PENYAKIT
1. Klien
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2. Keluarga
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E. POLA FUNGSIONAL KESEHATAN
1. Pemeliharandanpersepsiterhadapkesehatan
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2. Nutrisi / metabolic
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3. Polaeliminasi
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4. Polaaktivitasdanlatihan
Kemampuanperawatandiri 0 1 2 3 4
Makan / minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempattidur
Berpindah
Ambulasi ROM
Ket :
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
5. Oksigenasi
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6. Polatidurdanistirahat
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7. Polaperseptual
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8. Polapersepsidiri
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9. Polaseksualdanreproduksi
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10. Polaperan – hubungan
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11. Polamanajemenkoping stress
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12. Sistemnilaidankeyakinan
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G. PEMERIKSAAN FISIK
Keadaanumum:
GCS : ..................................................................................................
Tingkat kesadaran : (Composmetris/ Apatis/ Somnolen/ Supor/ Coma)
Tanda – tanda vital
TD : ..................................................................................................
Nadi : ..................................................................................................
Suhu : ..................................................................................................
RR : ..................................................................................................
BB : ..................................................................................................
TB : ..................................................................................................
LILA : ..................................................................................................
Head toetoe:
1. Kepala
Wajah
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Sclera
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Konjungtiva
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Pembesaranlimphe node
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Pembesarankelenjartiroid
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Telinga
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2. Kulit
Lineanigra :( )
Striaegravidarum :( )
Pucat :( )
Cloasma :( )
3. Dada
Payudara : ..................................................................................................
Areola : ..................................................................................................
Putting : ..................................................................................................
Tanda dimpling / retraksi : ..................................................................................................
Pengeluaran ASI : ..................................................................................................
Paru
Inspeksi : ..................................................................................................
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Palpasi : ..................................................................................................
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Perkusi : ..................................................................................................
Auskultasi : ..................................................................................................
Jantung
Inspeksi : ..................................................................................................
Palpasi : ..................................................................................................
Perkusi : ..................................................................................................
Auskultasi : ..................................................................................................
4. Abdomen
Linea : ..................................................................................................
Striae : ..................................................................................................
Pembesaran UK : ..................................................................................................
Gerakanjanin : ..................................................................................................
Kontraksi : ..................................................................................................
Luka bekasoprasi : ..................................................................................................
Ballottement : ..................................................................................................
Leopold I :Kepala / bokong / kosong
TFU : ..................................................................................................
Leopold II
Kanan :Punggung / bagiankecil / bokong / kepala
Kiri :Punggung / bagiankecil / bokong / kepala
Leopold III : presentasikepala / bokong / kosong
Leopold IV : Bagianmasuk PAP (konvergen / divergen / sejajar)
Penurunankepala : ..................................................................................................
Kontraksi : ..................................................................................................
DJJ : ..................................................................................................
Bisingusus : ..................................................................................................
5. Genetaliadan perineum
Kebersihan : ..................................................................................................
Pengeluaran : ..................................................................................................
Karakteristik : ..................................................................................................
Hemoroid : ..................................................................................................
Hasil VT : ..................................................................................................
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6. Ekstrimitas
Atas
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Bawah
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H. DATA PENUNJANG
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1. Diagnosamedis : ..................................................................................................
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2. Terapi
II. ANALISA DATA KALA 1