Sekolah Tinggi Ilmu Kesehatan

BINA USADA BALI

SK. Mendiknas RI. Nomor : 122/D/O/2007
TERAKREDITASI BAN PT.NOMOR 351/SK/BAN-PT/Akred/PT/IV/2015
Kompleks Kampus Mapindo, Jln. Padang Luwih Tegal Jaya Dalung-Badung.
Telp(0361)433132;Fax:(0361)419959;email:binausada@yahoo.com;website: binausadabali.ac.id

FORMAT PENGKAJIAN INTRANATAL

ASUHAN KEPERAWATAN MATERNITAS

Nama Mahasiswa : Tgl. Pengkajian:

NIM : Jam Pengkajian:
RS/Ruangan :
Tgl. Masuk RS :

A. IDENTITAS
Nama Pasien : Nama Suami :
Usia : Usia :
Jenis Kelamin : Pendidikan :
Pendidikan : Pekerjaan :
Pekerjaan : Status Perkawinan :
Agama :
Suku/Bangsa :
Alamat :
Diagnosa Medis Pasien :

B. DATA UMUM IBU

Keadaan umum : .................................................................................................................
Kesadaran : .........................................................................................................................
Tanda Vital
Tekanan Darah: .................mmHg Nadi:.......................x/menit
Suhu : ..................oC Pernafasan:.............x/menit
Tinggi Badan : ..............cm Indeks Masa Tubuh : ................
Berat Badan : ...............kg
Berat badan sebelum hamil : .........kg
Masalah kesehatan khusus :
Lain-lain, sebutkan : ..........................................................................................................
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Obat-obatan yang dikonsumsi : ..........................................................................................
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Alergi (obat/makanan/bagian tertentu) : .............................................................................
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Diet khusus selama hamil : .................................................................................................
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Alat bantu yang digunakan : (gigi tiruan/ kacamata/ lensa kontak/ alat dengar)*
Lain- lain, sebutkan ...................................................................................................
Frekuensi buang air kecil: ..............x/hari , masalah ..........................................................
Frekuensi buang air besar : ..............x/hari, masalah :........................................................
Kebiasaan waktu tidur : ..................jam

Riwayat Ginekologi
a. Riwayat menstruasi
Usia Menarche:
Siklus : teratur/tidak, ....... hari
Banyaknya :
Karakteristik Menarche:
b. Masalah ginekologi :
Riwayat penyakit menular seksual : Ada / Tidak, Jelaskan .......................................
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Pembedahan ginekologi : Pernah / Tidak, Jelaskan ....................................................
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Keganasan ginekologi : Ya / Tidak, Jelaskan .............................................................
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Pemeriksaan Papsmear : Ya / Tidak , Waktu pemeriksaan : ...................................
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Hasil Pemeriksaan Papsmear : .......................................................................................
Infertilitas : Tahun
Mioma Uteri :( ) Ya ( ) Tidak
Kista Ovarium :( ) Ya ( ) Tidak
Perdarahan pervaginam : ( ) Ya ( ) Tidak
Keluhan lainnya :( ) Ya ( ) Tidak
Sebutkan : .....................................................................................................................

Riwayat Pernikahan
Umur menikah :
Usia pernikahan :
Pernikahan yang ke- :
C. DATA UMUM MATERNITAS
Kehamilan saat ini direncanakan : Ya / Tidak
Status obstetrik : G..........P..........A.........H...........
HPHT :
Tafsiran partus :
Usia kehamilan : ....................minggu
Jumlah anak dirumah:
No Jenis Cara Tempat BB Komplikasi Keadaan Umur
Kelamin lahir persalinan dan lahir Saat ini
penolong

Riwayat mengikuti kelas prenatal : Ya / Tidak

Catatan khusus: ..................................................................................................................
Jumlah kunjungan ANC pada kehamilan ini : ...................................................................
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Masalah pada kehamilan yang lalu : ...................................................................................
a. Trimester I :
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b. Trimester II:
........................................................................................................................................
Trimester III:
........................................................................................................................................
Masalah pada kehamilan sekarang ; ...................................................................................
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Kontrasepsi yang pernah dipakai : ......................................................................................
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Masalah yang pernah dialami selama penggunaan kontrasepsi : .......................................
Rencana KB setelah kehamilan ini : ...................................................................................
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Makanan bayi sebelumnya : ASI / MPASI / lainnya: .....................................................
Edukasi yang ingin ibu dapatkan selama perawatan: (Lingkari)
Teknik relaksasi / pernafasan / manfaat ASI dan cara menyusui yang baik / cara
memberi minum botol / senam nifas / metode KB / perawatan perineum / perawatan
payudara Lain-lain, jelaskan .............................................................................................
Setelah bayi lahir, yang diharapkan membantu perawatan : suami/ teman / kerabat /
orang tua. Lainnya, jelaskan ...............................................................................................
Masalah persalinan yang lalu ..............................................................................................
Kebiasaan yang merugikan ibu
Merokok ( ) Obat-obatan terlarang ( )
Alkohol ( ) Obat-obatan yang dijual bebas ( )
D. DATA PSIKOSOSIAL
1. Riwayat psikologis selama hamil :
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2. Interaksi ibu selama kehamilan :
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3. Harapan ibu selama kehamilan :
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4. Peran yang dilakukan ibu selama hamil :
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5. Perasaan ibu terhadap kehamilan sekarang :
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6. Penghasilan keluarga setiap bulan :
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7. Perasaan suami terhadap kehamilan sekarang :
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8. Jelaskan respon sibling terhadap kehamilan sekarang :
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E. RIWAYAT PERSALINAN SEKARANG

Mulai persalinan : Tanggal .................................... Jam : .................................................
1. Keadaan kontraksi : Frekuensi dalam 10 menit ..........................................................
Lamanya.....................................................................................
Kekuatan ....................................................................................
2. Denyut jantung Janin: Frekuensi : ...................x/menit
 Kualitas : .............................................................................
3. Status Janin : Hidup/Tidak : ....................................................................................
Jumlah : ............................................................................................
Presentasi : .......................................................................................
4. Pemeriksaan fisik
Tanda Vital
Tekanan Darah: .................mmHg Nadi:.......................x/menit
Suhu : ..................oC Pernafasan:.............x/menit
Head to Toe
Kepala:
a. Leher : ....................................................................................................................
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b. Kepala : ..................................................................................................................
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c. Mata : .....................................................................................................................
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d. Hidung : .................................................................................................................
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e. Mulut : ...................................................................................................................
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f. Telinga : .................................................................................................................
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Dada :
a. Jantung : .................................................................................................................
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b. Paru-paru : .............................................................................................................
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c. Payudara : ..............................................................................................................
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d. Pengeluaran ASI: Ya / Tidak, jelaskan ................................................................
...............................................................................................................................
e. Puting susu: eksverted / datar ./ inverted / lecet, jelaskan ...............................

Abdomen: a. Uterus :
Tinggi fundus uteri : ............cm
b. Letak : ( ) Puka / ( ) Puki
c. Presentasi :.....................................................................................
d. Penurunan bagian terendah: ..................................................................
e. Tafsiran Berat Janin : …………….. gram
f. Auskultasi (DJJ) : …………….. x/menit
g. Kontraksi / His : ( ) Ya / ( ) Tidak, ( )Teratur /( ) Tidak teratur
h. Bekas Operasi ( ) Ya ( ) Tidak
Hiperpigmentasi : Ya / Tidak
Pigmentasi : a. Linea nigra : Ya / Tidak , letaknya ...........................
b. Striae : Ya/ Tidak, letaknya................................
Hemoroid : Derajat :
Lokasi :
Berapa lama :
Nyeri : Ya / Tidak
Ekstremitas :
a. Ekstremitas Atas : Edema : Ya / Tidak
Inspeksi :
Palpasi: varises :
b. Ekstremitas Bawah : Inspeksi :
Palpasi :
Varises :
Reflek Patela : + / - , Jika ada: +1 / +2 / +3
5. Hasil periksa dalam :
Jam pemeriksaan Oleh Hasil

6. Ketuban : Utuh / Pecah

Jika sudah pecah : Tanggal.............................Jam ..................... Warna ......................
7. Laboratorium
Tanggal :
Pemeriksaan Darah Lengkap
Jenis Hasil Satuan Nilai normal Intepretasi
pemeriksaan Min Max
 Pemeriksaan UL :
Jenis pemeriksaan Hasil Nilai normal Satuan

8. Terapi yang diberikan

Tanggal Jenis Terapi Rute Dosis Indikasi Terapi
Terapi

9. Dilakukan klisma/huknah, ( Ya / Tidak), Jelaskan: ..................................................

10. Perdarahan pervaginam ( Ya / Tidak ), Jelaskan : .....................................................
 LAPORAN PERSALINAN

PERSALINAN KALA I
Mulai persalinan : Tanggal :...................................... Jam: ..........................
Tanda dan gejala :
Tanda Vital
Tekanan Darah: .................mmHg Nadi:.......................x/menit
Suhu : ..................oC Pernafasan:.............x/menit
Lama Kala I
.....................................jam ............................... menit ................................. detik
Keadaan psikososial :
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Kebutuhan khusus klien :
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Pengobatan :
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Observasi kemajuan persalinan:
Tanggal Jam Hasil Observasi
ASUHAN KEPERAWATAN KALA I
HARI/ MASALAH
ANALISA DATA ETIOLOGI
TANGGAL KEPERAWATAN
DIAGNOSA KEPERAWATAN
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INTERVENSI KEPERAWATAN KALA I
NO TUJUAN &
DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
KRITERIA HASIL
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA I
Tanggal Jam Diagnosa Keperawatan Implementasi Respon Pasien Paraf Jam Evaluasi (SOAP) Paraf
PERSALINAN KALA II
Kala II dimulai: Tanggal : .................................. Jam :...............................................
Tanda Vital
Tekanan Darah: .................mmHg Nadi:.......................x/menit
Suhu : ..................oC Pernafasan:.............x/menit
Lama Kala II
.....................................jam ............................... menit ................................. detik
Tanda dan gejala :
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Upaya meneran :
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Keadaan Psikososial :
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Kebutuhan khusus :
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Observasi persalinan:
Tanggal Jam Hasil Observasi
ASUHAN KEPERAWATAN ALA II
HARI/ MASALAH
ANALISA DATA ETIOLOGI
TANGGAL KEPERAWATAN

DIAGNOSA KEPERAWATAN
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INTERVENSI KEPERAWATAN KALA II
NO TUJUAN &
DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
KRITERIA HASIL
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA II
Tanggal Jam Diagnosa Keperawatan Implementasi Respon Pasien Paraf Jam Evaluasi (SOAP) Paraf
CATATAN KELAHIRAN
Kelahiran Bayi : Jam........................
Jenis kelamin :…………………………………....................................................................
BB/PB/lingkar kepala bayi :…........... gram / ............. cm / ................ cm
Karakteristik khusus bayi :………………………………........................................................
Kaput : suksedaneum/cephalhematom
Suhu :.................... OC
Anus: berlubang/tertutup
Perawatan tali pusat :………………………………...............................................................
Perawatan mata :………………………………......................................................................
APGAR SCORE
No Tanggal Jam Karakteristik yang dinilai 0 1 2

Denyut jantung
Pernafasan
Refleks
Tonus otot
Warna kulit

Total menit I ...............................................

menit V ...............................................
Perineum (utuh/episiotomi/ruptur), jika ruptur,tingkat.............................................................
Bonding ibu dan bayi :
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PERSALINAN KALA III
Tanda dan gejala :
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Plasenta lahir, jam.......................................
Cara lahir plasenta :
Karakteristik Plasenta: Ukuran..........gr x......cm x........ cm
Panjang tali pusat............................................................ cm
Jumlah pembuluh darah: Arteri…………………….......Vena…........................................
Kelainan:...............................................................................................................................
Perdarahan :……………...... ml, karakteristik.......................................................................
Keadaan psikososial : ..............................................................................................................
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Kebutuhan khusus : .................................................................................................................
Observasi persalinan:
Tanggal Jam Hasil Observasi

ASUHAN KEPERAWATAN KALA III

HARI/ MASALAH
ANALISA DATA ETIOLOGI
TANGGAL KEPERAWATAN

DIAGNOSA KEPERAWATAN
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INTERVENSI KEPERAWATAN KALA III
NO TUJUAN &
DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
KRITERIA HASIL
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA III
Tanggal Jam Diagnosa Keperawatan Implementasi Respon Pasien Paraf Jam Evaluasi (SOAP) Paraf
PERSALINAN KALA IV
Hasil Observasi
Jam Kontraksi Kandung
Waktu TD Nadi Suhu TFU Pendarahan
Ke Uterus Kemih

ASUHAN KEPERAWATAN KALA IV

HARI/ MASALAH
ANALISA DATA ETIOLOGI
TANGGAL KEPERAWATAN

DIAGNOSA KEPERAWATAN
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INTERVENSI KEPERAWATAN KALA IV
NO TUJUAN &
DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
KRITERIA HASIL
IMPLEMENTASI DAN EVALUASI KEPERAWATAN KALA IV
Tanggal Jam Diagnosa Keperawatan Implementasi Respon Pasien Paraf Jam Evaluasi (SOAP) Paraf