MUHAMMADIYAH MANADO
PROGRAM STUDI SI KEPERAWATAN
Alamat : Jl. Sasuit Tubun No. 9. Kel. Istiqlal Kec. Wenang – Manado
Telp : 0431 – 850372 HP : 085240134436 / Fax : 0431 – 870358
E-mail : stikesmuhammadiyahmdo@yahoo.com
PENGKAJIAN PRENATAL
Riwayat Ginekologi
1. Masalah ginekologi :
2. Riwayat KB :
Kepala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah Khusus : ..........................................................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI :
Masalah Khusus : ............................................................................................
Abdomen
Uterus
TFU :....................cm kontraksi : ya/tidak
Leopold I : kepala/bokong/kosong
Leopold II : kanan : punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/bokong/kepala
Leopold III : kepala/bokong/kosong
Leopold IV : bagian masuk PAP
Pigmentasi
Linea nigra :
Striae
Fungsi pencernaan :
Masalah Khusus : ...........................................................................................
Perineum dan Genital
Vagina : varises; ya/tidak
Kebersihan :…….
Keputihan :
Jenis/warna :.......................Konsistensi : ....................... Bau : .......................
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :..................................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Refleks patela : +/- jika ada : +1/+2/+3
Masalah khusus : ………………………………………………………
Eliminasi
Urin : kebiasaan BAK……………………………………………
Fekal : kebiasaan BAB.............................................................
Masalah Khusus :.....................................................................................
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ..................................................................................
Nutrisi dan Cairan
Asupan nutrisi : ....................................nafsu makan : baik/kurang/tidak ada
Asupan cairan : ...................................cukup/kurang
Masalah khusus : ...........................................................................................
Keadaan Mental
Adaptasi psikologis : ......................................................................................
Penerimaan terhadap kehamilan :..................................................................
Masalah khusus : ..........................................................................................
Pola hidup yang meningkatkan risiko kehamilan : ...........................................................
Persiapan Persalinan
□ Senam hamil
□ Rencana tempat melahirkan
□ Perlengkapan kebutuhan bayi dan ibu
□ Kesiapan mental ibu dan keluarga
□ Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses persalinan
□ Perawatan payudara
Obat-obatan yang dikonsumsi saat ini :
Hasil pemeriksaan penunjang :
PENGKAJIAN INTRANATAL
I. DATA UMUM
Inisial klien : ................ (.....th) Nama Suami : .............................(......th)
Pekerjaan : ............................... Pekerjaan : .............................................
Pendidikan Terakhir : .............. Pendidikan terakhir :.............................
Agama : ................................... Agama : .............................................
Suku bangsa :......................
Status perkawinan : ......................................................
Alamat : .........................................................................................................
II. DATA UMUM KESEHATAN
TB/BB : ................cm/.................kg
BB sebelum hamil : .....................kg
Masalah kesehatan khusus : ...........................................................................
Obat-obatan : .................................................................................................
Alergi (obat/makanan/bahan tertentu) : .........................................................
Diet khusus : ..................................................................................................
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain-lain : .......................................................................................................
Frekuensi BAB/BAK :...................................................................................
Masalah BAB/BAK : ..............................................................................................
Kebiasaan waktu tidur : ..............................................................................................
V. DATA PSIKOSOSIAL
Penghasilan keluarga setiap bulan : ............................................................................
Perasaan klien terhadap kehamilan sekarang : ..........................................................
Perasaan suami terhadap kehamilan sekarang : ........................................................
Jelaskan respon sibling terhadap kehamilan sekarang : .............................................
LAPORAN PERSALINAN
I. Pengkajian awal
Tanggal : .........................Jam : ............................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Pemeriksaan palpasi abdomen
Leopold I : ..............................................................................
Leopold II : . ..............................................................................
Leopold III : ..............................................................................
Leopold IV : ..............................................................................
Hasil pemeriksaan dalam : ...............................................................................
Pemeriksaan perineum : .........................................................................................
Dilakukan klisma (ya/tidak) : .............
Pengeluaran pervaginam : ................................................................
Perdarahan pervaginam (ya/tidak) :.................
Kontraksi uterus (frekuensi, lamanya, kekuatan) : ................................................
DJJ : (frekuensi/kualitas)................................./.....................................................
Status janin : (hidup/tidak,jumlah,presentasi) : .....................................................
...............................................................................................................................
II. Kala persalinan
Kala I
Mulai persalinan : (tanggal/jam)............................................................................
Tanda dan gejala : .................................................................................................
Lama Kala I : (jam/menit/detik)............................................................................
Keadaan psikososial : ...........................................................................................
Kebutuhan khusus klien : .....................................................................................
Tindakan : ............................................................................................................
Pengobatan : .........................................................................................................
Observasi kemajuan persalinan :
Tanggal/jam Kontraksi DJJ Keterangan
uterus
Kala II
Kala II dimulai : (Tgl/jam) : ...................................................................................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Lama kala II : (jam/menit/detik) ...................................................................................
Keadaan psikososial : ...................................................................................................
Kebutuhan khusus klien : .............................................................................................
Tindakan : .....................................................................................................................
Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur : ................................
Bonding ibu dan bayi :.......................
TTV bayi : TD......................mmHg,N...............x/mnt S...............oC P..............x/mnt
Pengobatan : .................................................................................................................
Catatan kelahiran :
Bayi lahir jam : .......................................
Jenis kelamin : ........................................
Nilai APGAR menit I................................menit V...........................
BB/PB/lingkar kepala : .........................gram.........................cm....................cm
Karakteristik khusus bayi : ..........................................................................................
Kaput suksadaneum/cephal hematoma : ......................................................................
Anus : berlubang/tertutup*
Perawatan tali pusat :..............................................................
Perawatan mata : ...................................................................
Kala III
Mulai jam : .................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Tanda dan gejala :...........................................................................................................
Plasenta lahir jam : ........................................................................................................
Cara lahir plasenta :.........................................................................
Karakteristik plasenta .....................................................................
Diameter : ..........cm
Ketebalan : .............cm
Panjang tali pusat : ..........................................................................
Jumlah pembuluh darah :.........................arteri .......................vena
Insersio tali pusat : ..........................................................................
Kelainan : ........................................................................................
Perdarahan : .........................ml
Karakteristik perdarahan : ...............................................................
Keadaan psikososial : ......................................................................
Kebutuhan khusus : .........................................................................
Tindakan : .......................................................................................
Pengobatan : ....................................................................................
Kala IV
Mulai jam : ................
TTV : TD......................mmHg,N.......................x/mnt S...............oC P..............x/mnt
Kontraksi uterus : ..........................................................................................................
Perdarahan :......................ml
Karakteristik : ...............................................................................................................
Tindakan : ....................................................................................................................
LAPORAN PARTUS NORMAL
” SYAIR OBSTETRI ”
Nama Klien :
Status Obstetri :
Kepala Leher
Kepala :
Mata :
Hidung :
Mulut :
Telinga :
Leher :
Masalah Khusus : .....................................................................................
Dada
Jantung :
Paru :
Payudara :
Puting susu :
Pengeluaran ASI :
Masalah Khusus : .....................................................................................
Abdomen
Involusi Uterus
Fundus Uteri :....................kontraksi : .................Posisi :......................
Kandung kemih
Diastasis rektus abdominis ......................x......................cm
Fungsi pencernaan :
Masalah Khusus : .................................................................................
Perineum dan Genital
Vagina : integritas kulit.....edema.....memar.....hematom.........
Perineum : Utuh/episiotomi/ruptur Tanda REEDA
R : Kemerahan : ya/tidak
E : Edema : ya/tidak
E : Ekimosis : ya/tidak
D : Dischargeserum/pus/darah/tidak ada
A : Approximate : baik/tidak
Kebersihan :…….
Lokia :
Jumlah : ............Jenis/warna :..............Konsistensi : .............Bau : ............
Hemorrhoid :
Derajat :...................... lokasi : .....................
Berapa lama : ........ nyeri : ya/tidak
Masalah khusus :...............................................................................................
Ekstremitas
Ekstremitas Atas
Edema : ya/tidak
Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak
Varises : ya/tidak
Tanda Homan : +/-
Masalah khusus : ……………………………………………..............
Eliminasi
Urin : kebiasaan BAK……………………………………………
BAK saat ini......................................nyeri/tidak
Fekal : kebiasaan BAB.............................................................
BAB saat ini.....................................konstipasi/tidak :
Masalah Khusus :...................................................................................
Istirahat dan Kenyamanan
Pola tidur : kebiasaan tidur, lama...jam, frekuensi........ Pola tidur saat ini..........
Keluhan ketidaknyamanan : ya / tidak, lokasi............sifat..............intensitas......
Mobilisasi dan Latihan
Tingkat mobilisasi :.........................................................................
Latihan/senam : ........................................................................
Masalah khusus : ........................................................................
Nutrisi dan Cairan
Asupan nutrisi : ....................nafsu makan : baik/kurang/tidak ada
Asupan cairan : ...................................cukup/kurang
Masalah khusus : ............................................................................
Keadaan Mental
Adaptasi psikologis : .....................................................................
Penerimaan terhadap bayi :...........................................................
Masalah khusus : ...........................................................................
Kemampuan menyusui: .................................................................................
Obat-obatan yang dikonsumsi saat ini :
Masalah :
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Perencanaan Pulang :
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