PENGKAJIAN INTRANATAL

ASUHAN KEPERAWATAN PADA NY..... ......... G...P...A...

HAMIL ... MINGGU DI RUANG DARUSSALAM 2
RUMAH SAKIT AL-ISLAM KOTA BANDUNG

A. PENGAKAJIAN
1. Identitas klien
Nama :
No. Medrec :
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Agama :
Suku bangsa :
Status marital :
Golongan darah :
Tanggal masuk RS :
Tanggal pengkajian :
Diagnosa medis :
2. Identitas penanggung jawab
Nama :
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Agama :
Suku bangsa :
Status marital :
Golongan darah :
Hubungan dengan klien :
3. Riwayat Kesehatan
KALA I
1) Keluhan Utama
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2) Riwayat Kesehatan Sekarang
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3) Riwayat Kesehatan Dahulu
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4) Riwayat Kesehatan Keluarga
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5) Riwayat Gynekologi & Obstetri
a) Riwayat Obstetri
(1) Riwayat kehamilan, persalinan dan nifas yang lalu
Tempat Masalah Keadaan
Thn. Umur Jenis
No / JK BB Ha Anak
Partus Hamil Partus Lahir Nifas Bayi
Penolong mil
 ( x )+( x )

=
(2) Riwayat kehamilan sekarang
Tanggal periksa : =
HPHT : -
=

=
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b) Riwayat Gynekologi
(1) Riwayat Menstruasi
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(2) Riwayat Perkawinan
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(3) Riwayat Keluarga Berencana
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4. Pemeriksaan Fisik
a. Keadaan umum
TD : mmHg RR : x/menit
HR : x/menit S : ºC
BB : kg TB : cm
b. Sistem reproduksi
1) Payudara
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2) Fundus Uteri
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3) Vulva atau vagina
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c. Sistem perkemihan
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d. Terapi
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e. Pemeriksaan penunjang
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5. ANALISA DATA
Data Etiologi Masalah
 B. DIAGNOSA KEPERAWATAN
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2. .......................................................................................................................
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C. INTERVENSI

No Dx. Kep Tujuan Intervensi Rasional

D. IMPLEMENTASI

Tanggal Dx Waktu Implementasi

E. EVALUASI

Dx.Kep Tanggal Waktu Evaluasi

KALA II
A. PENGKAJIAN
1) Keluhan Utama
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2) Riwayat penyakit sekarang
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3) Pemeriksaan fisik ibu
Abdomen : .....................................................................................................
Genetalia:........................................................................................................
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4) Terapi
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B. ANALISA DATA
Data Etiologi Masalah
 C. DIAGNOSA KEPERAWATAN
1. ........................................................................................................................
2. ........................................................................................................................
3. ........................................................................................................................
D. INTERVENSI
No Dx. Kep Tujuan Intervensi Rasional
No Dx. Kep Tujuan Intervensi Rasional

a.
E. IMPLEMENTASI
Tanggal Dx Waktu Implementasi
F. EVALUASI
Dx.Kep Tanggal Waktu Evaluasi
KALA III
A. PENGKAJIAN
1) Keluhan Utama
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2) Riwayat penyakit sekarang
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3) Pemeriksaan fisik
a) Abdomen :
b) Genetalia :

c) Ektremitas :

4) Terapi

B. ANALISA DATA
Data Etiologi Masalah
C. DIAGNOSA KEPERAWATAN
1.
2.
3.
 D. INTERVENSI
No Dx. Kep Tujuan Intervensi Rasional
E. IMPLEMENTASI
Tanggal Dx Waktu Implementasi

F. EVALUASI
Dx.Kep Tanggal Waktu Evaluasi
KALA IV
A. PENGKAJIAN
1) Keluhan Utama
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2) Riwayat penyakit sekarang
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3) Pemeriksaan fisik ibu
5) Pemeriksaan fisik
d) Abdomen :
e) Genetalia :

f) Ektremitas :
B. ANALISA DATA
Data Etiologi Masalah
 C. DIAGNOSA KEPERAWATAN

2. INTERVENSI
No Dx. Kep Tujuan Intervensi Rasional
3. IMPLEMENTASI
Tanggal Dx Waktu Implementasi
4. EVALUASI
Dx.Kep Tanggal Waktu Evaluasi