ASUHAN KEPERAWATAN INTRANATAL PADA ______

DI RUANG BERSALIN RSUD KARANGANYAR

Di Susun Untuk Memenuhi Tugas

Stase Keperawatan Maternitas

Di Susun Oleh:
ELIAN EVIANI
NIM : 2016131042

PROGRAM PROFESI NERS

FAKULTAS ILMU KESEHATAN
UNIVERSITAS SAHID SURAKARTA
TAHUN 2017
PENGKAJIAN INTRANATAL

Nama Mahasiswa : .................................................. NPM : ..........................

Tempat Praktik : .................................................. TGL : ..........................

I. DATA UMUM
Inisial klien : .......................................................................................
Umur : .......................................................................................
Agama : .......................................................................................
Suku Bangsa : .......................................................................................
Penidikan terakhir : .......................................................................................
Status pernikahan : .......................................................................................
Nama Suami : .......................................................................................
Umur Suami : .......................................................................................
Pekerjaan Suami : .......................................................................................

II. DATA UMUM KESEHATAN

1. TB/BB : ...........................................................................
2. BB Sebelum Hamil : ...........................................................................
3. Masalah Kesehatan
Khusus : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
4. Obat-obatan : ...........................................................................
5. Alergi : ...........................................................................
6. Eliminasi BAK : ...........................................................................
7. Elimiminasi BAB : ...........................................................................
8. Pola Tidur : ...........................................................................
III. DATA UMUM KEBIDANAN

1. Kehamilan sekarang
direncanakan : Ya / Tidak
2. Status Obstetri : G .... P .... A ....
3. HPHT : ...........................................................................
4. Jumlah anak dirumah
No Jenis Cara BB Keadaan Umur
1
2
3
4
5

5. Mengikuti kelas perinatal : ...............................................................

6. Jumlah kunjungan
pada kehamilan ini : ...............................................................
7. Masalah kehamilan sebelumnya : ...............................................................
...............................................................
8. Masalah persalinan sebelumnya : ...............................................................
...............................................................
9. Masalah kehamilan sekarang : ...............................................................
10. Riwayat KB : ...............................................................
11. Makanan bayi sebelumnya : ASI / PASI
Lain-lain : ...............................................................
12. Pelajaran apa yang diinginkan
saat ini : Relaksasi / Pernafasan / Manfaat ASI /
cara memberi ASI / senam nifas /
metode KB / perawatan perineum /
perawatan payudara.
13. Setelah lahir siapa yang di -
harapkan membantu : Suami / Teman / Orang Tua
IV. RIWAYAT PERSALINAN SEKARANG

a. Mulai persalinan
(kontraksi/pengeluaran pervaginam) : ...................................................
b. Keadaan kontraksi
(frekuensi dalam 10 menit,
lamanya, kekuatan) : ...................................................
...................................................
c. Frekuensi dan kualitas DJJ : ...................................................

d. Pemeriksaan fisik
Kenaikan BB selama hamil : ...............................................................
Tanda-tanda vital
TD : .................................. Nadi : ..................................
Nadi : .................................. Suhu : ..................................
Kepala dan Leher : Normal / Tidak
Jantung : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
Payudara : ...........................................................................
...........................................................................
...........................................................................
Abdomen : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
DJJ : ...........................................................................
Ektremitas : Oedema / Tidak
e. Pemeriksaan penunjang
PEMERIKSAAN HASIL NILAI SATUAN
RUJUKAN
HEMATOLOGI
Hemoglobin
Hematokrit
Lekosit
Trombosit
Eritrosit
MPV
PDW
INDEX
MCV
MCH
MCHC
HITUNG JENIS
Gran%
Limfosit%
Monosit%
Eosinofil%
Basofil%
Masa Pembekuan (CT)
Masa Perdarahan (BT)
Golongan Darah
KIMIA
GULA DARAH
Gula Darah Sewaktu
GINJAL
Creatinin
Ureum
f. Terapi Medis
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
 LAPORAN PERSALINAN

I. PENGKAJIAN AWAL

1. Tanggal/Jam : .......................................................................................
2. Tanda-tanda vital
TD : ...............................
Nadi : ...............................
RR : ...............................
Suhu : ...............................
3. Pemeriksaan palpasi
abdomen : .......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
.......................................................................................
4. Hasil periksa dalam : ...................................................
5. Persiapan perineum : ...................................................
6. Dilakukan klisma : Ya / Tidak
7. Pengeluaran pervaginam : ...................................................
8. Perdarahan pervaginam : Ya / Tidak
9. Kontraksi uterus : ...................................................
10. Denyut Jantung Janin : ...................................................
11. Status Janin : Hidup / Tidak

II. KALA PERSALINAN

KALA I
1. Mulai kala I tanggal : ............................. Jam : ...............................
2. Lama kala I : ...........................................................................
3. Tanda dan gejala : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
...........................................................................
4. Hasil pemeriksaan : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
5. Keadaan psikososial : ...........................................................................
...........................................................................
...........................................................................
...........................................................................
6. Kebutuhan khusus ibu : ...........................................................................
...........................................................................
7. Tindakan : ...........................................................................
8. Pengobatan : ...........................................................................
KALA II
1. Mulai tanggal : ................................. Jam: ............................................
2. Lama kala II : ...........................................................................
3. Tanda dan gejala : ...........................................................................
............................................................................
4. Hasil pemeriksaan
dalam : ...........................................................................
...........................................................................
5. Persiapan perineum : ...........................................................................
6. Penjelasan upaya
Meneran : ...........................................................................
...........................................................................
7. Keadaan psikososial : ...........................................................................
8. Tindakan : ...........................................................................
Kala III
1. Tanda dan gejala : ...........................................................................
...........................................................................
2. Tindakan : ...........................................................................
3. Plasenta lahir jam : ...........................................................................
4. Cara lahir plasenta : ...........................................................................
5. Karakteristik plasenta : ...........................................................................
6. Panjang tali pusat : ...........................................................................
7. Pembuluh darah : ...........................................................................
8. Kelainan : ...........................................................................
9. Perdarahan : ...........................................................................
10. Keadaan psikososial
Ibu : ...........................................................................
...........................................................................
11. Keadaan perineum : ...........................................................................
12. Kebutuhan khusus ibu : ...........................................................................
13. Tindakan : ...........................................................................
14. Pengobatan : ...........................................................................
KALA IV
a. Mulai jam : .......................................................................................

b. TTV : suhu ........., TD ........... mmgh, nadi .......... x/menit

RR .......... x/menit
c. Keadaan uterus : ...........................................................................

d. Perdarahan : ...........................................................................

e. Bonding ibu dan bayi : ...........................................................................

f. Tindakan : ...........................................................................
...........................................................................
...........................................................................
g. Pengobatan : ...........................................................................
BAYI
a. Bayi lahir tanggal/jam : ...........................................................................
b. Jenis kelamin : ...........................................................................
c. Nilai ABGAR
ABGAR SCORE Menit 1 Menit 5 Menit 10
Jantung
Nafas
Otak
Rangsang
Warna
Jumlah

d. BB/Pb bayi : ................... gram

e. Karakteristik bayi : ...........................................................................
...........................................................................
f. Lingkar kepala : ...........................................................................
g. Kaput suksedaneum : ...........................................................................
h. Suhu : ...........................................................................
i. Anus : Berlubang / Tertutup
j. Perawatan tali pusat : ...........................................................................
k. Perawatan mata : ...........................................................................
 ANALISA DATA

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................
Diagnosa Medis : .................................................. Tanggal : ..................................................

N DATA DIAGNOSA KEPERAWATAN TTD

O
 RENCANA KEPERAWATAN

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................

N DIAGNOSA KEPERAWATAN TUJUAN DAN KH INTERVENSI RASIONAL

O
N DIAGNOSA KEPERAWATAN TUJUAN DAN KH INTERVENSI RASIONAL
O
 CATATAN KEPERAWATAN

Inisial Klien : .................................................. No. RM : ..................................................

Usia : .................................................. Ruang : ..................................................

N
O TANGGAL IMPLEMENTASI EVALUASI TTD
DX
N IMPLEMENTASI EVALUASI TTD
O TANGGAL
DX