FORMAT PENGKAJIAN INTRANATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

A. IDENTITAS
1. Nama pasien : ................................. Nama Suami : …….....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

B. STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
....................................................................................................................................
..........………………………………………………………………………………
………..…
2. Keluhan utama saat ini : ..................................................................……..................
....................................................................................................................................
..........………………………………………………………………………………
…….……
3. Riwayat Kondisi saat ini

4. Diagnosa medik : ...........................................................................……....................

C. RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak ( )
 Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
 HPHT : ............................
 TP :

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 b. Riwayat kehamilan, persalinan, nifas :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Usia Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan

c. Genogram :
D. RIWAYAT KELUARGA BERENCANA :
a. Melaksanakan KB : ( ) ya ( ) tidak
b. Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
c. Sejak kapan menggunakan kontrasepsi : ................................................................
d. Masalah yang terjadi : ............................................................................................

E. RIWAYAT KESEHATAN :
a. Penyakit yang pernah dialami ibu : ........................................................................
b. Pengobatan yang didapat : ......................................................................................
c. Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

F. RIWAYAT LINGKUNGAN :
- Kebersihan :
...........................................................................................................…………….......
- Bahaya :
…………......................................................................................................................
- Lainnya sebutkan :
.................................................................................…………………….....................

G. ASPEK PSIKOSOSIAL :
1. Persepsi ibu tentang keluhan/ penyakit : ................................................................
2. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?
............
Bila ya bagaimana ..................................................................................................
3. Harapan yang ibu inginkan : ..................................................................................
4. Ibu tinggal dengan siapa : .......................................................................................
5. Siapakah orang yang terpenting bagi ibu................................................................
6. Sikap anggota keluarga terhadap keadaan saat ini .................................................
7. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

H. KEBUTUHAN DASAR KHUSUS (DI RUMAH DAN DI RS) :

1. Pola Nutrisi
a. Frekwensi makan : .............................. x sehari
b. Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
c. Jenis makanan rumah : ................................................................................….
d. Makanan yang tidak disukai/ alergi/ pantangan : .............................................
2. Pola eliminasi :
a. B A K
a. Frekwensi : ....................kali
b. Warna :
.......................……………………………………………….
c. Keluhan saat BAK : .................................................………......................

b. B A B
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
a. Konsistensi : .............……………………………………………….........
b. Keluhan ....................................................................………....

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 3. Pola personal hygiene
a. Mandi
a. Frekwensi : ...................................x /hari
b. Sabun : ( ) ya, ( ) tidak
b. Oral hygiene
a. Frekwensi : ...................................x /hari
b. Waktu : ( ) ya, ( ) tidak
c. Cuci rambut
a. Frekwensi : ...................................x /hari
b. Shampo : ( ) ya, ( ) tidak
4. Pola istirahat dan tidur
a. Lama tidur : ............................jam/hari
b. Kebiasaan sebelum tidur : ................................................................................
c. Keluhan : ..........................................................................................................
5. Pola aktifitas dan latihan
a. Kegiatan dalam pekerjaan : ..............................................................................
b. Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
c. Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
d. Kegiatan waktu luang : .....................................................................................
e. Keluhan dalam beraktifitas : ............................................................................
6. Pola kebiasaan yang mempengaruhi kesehatan
a. Merokok :
..............................................................................................
b. Minuman keras :
..............................................................................................
c. Ketergantungan obat :
..............................................................................................
I. PEMERIKSAAN FISIK
a. Keadaan umum : ......................................Kesadaran : .........................
b. Tekanan darah : ......................................Nadi : .............x/menit
c. Respirasi : .....................................Suhu : .......…........C
d. Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :
Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak mata : .....................................................................................................
 Gerakan mata : ....................................................................................................
 Konjungtiva : .....................................................................................................
 Sklera : ....................................................................................................
 Pupil : .....................................................................................................
 Akomodasi : .....................................................................................................
 Lainnya sebutkan : .................................................................................................

Hidung :
 Reaksi alergi : .....................................................................................................
 Sinus : ....................................................................................................
 Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
 Gigi geligi : .....................................................................................................
 Kesulitan menelan : ................................................................................................
 Lainnya sebutkan : .................................................................................................

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 Dada dan Axilla
 Mammae : membesar ( ) ya ( ) tidak
 Areolla mammae : ..................................................................................................
 Papila mammae : ....................................................................................................
 Colostrum : .....................................................................................................

Pernafasan
 Jalan nafas : .....................................................................................................
 Suara nafas . : ....................................................................................................
 Menggunakan otot-otot bantu pernafasan : ............................................................
 Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ...............................................................................................
 Kelainan bunyi jantung : ........................................................................................
 Sakit dada : ...............................................................................................
 Timbul .: ...............................................................................................
 Lainnya sebutkan : ..............................................................................................

Abdomen
 Tinggi fundus uterus: cm Kontraksi: ya/ tidak Frekuensi:
 Leopold I :
 Leopold II :
 Leopold III:
 Leopold IV:
 Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :

Genitourinary
 Perineum : ...............................................................................................
 Vesika Urinasria : ...............................................................................................
 Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
 Vagina :
 Kebersihan :
 Keputihan :
 Jenis/warna :

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

J. KESIAPAN DALAM PERSALINAN:

1. Kesiapan mental ibu dan keluarga
2. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan
proses persalinan

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K. RIWAYAT PERSALINAN SEKARANG
KALA 1
Mulai kontraksi : tanggal..............................jam.........................
Interval dan lama kontraksi :
Tanda dan gejala : .........................................................................
Tanda-tanda vital
TD: mmHg Nadi : x/menit Suhu : c RR: ..............X/menit
Lama kala I
Keadaan psikososial

Tindakan
Pengobatan
Observasi kemajuan persalinan
Tanggal/ jam Kontraksi Uterus TTV DJJ VT

KALA II
Kala II dimulai
Tanggal...................................................jam..............................................
Tanda-tanda vital
TD: mmHg Nadi : x/menit Suhu : c RR: ..............X/menit
Lama kala II...................................
Tanda dan gejala...........................................
Jelaskan upaya meneran.........................................
Keadaan psikososial....................................................
Kebutuhan Khusus......................................................
Tindakan/ Pengobatan................................................................
Perineum (utuh/episiotomi/ ruptur)......................................

CATATAN KELAHIRAN BAYI

Bayi lahir jam :
Nilai APGAR, menit I........................................menit V...................................
Bonding ibu dan bayi........................................................................................

KALA III
Tanda dan gejala...........................................
Plasenta lahir..................................................
Karakteristik plasenta.....................................
Perdarahan..................ml, karakteristik..........................
Keadaan psikososial........................................................
Kebutuhan khusus..........................................................
Tindakan.........................................................................
Pengobatan....................................................................

KALA IV
Mulai jam.............................
Tanda-tanda vital
TD: mmHg Nadi : x/menit Suhu : c RR: ..............X/menit

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 Kontraksi uterus................................................
Perdarahan........................................................
Bonding ibu dan bayi..........................................
Tindakan.............................................................

DATA BAYI
Bayi lahir tanggal/ jam..................................
Jenis kelamin................................................
Nilai APGAR..................................................
BB/PB/Lingkar kepala bayi.................gram..................cm................cm
Kelainan Kepala
Suhu...........................c
Anus: berlubang/ tertutup
Perawatan tali pusat.................................
Perawatan mata..........................................

L. DATA PENUNJANG
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
....................................................................................................................................
....................................................................................................................................
.....................................................................................................

M. DATA TAMBAHAN
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................
Surabaya, ........................................
Pemeriksa

(..................................................)