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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 Persalinan saat ini

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

C. RIWAYAT KEPERAWATAN

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

1
2
b. Riwayat kehamilan, persalinan, nifas :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Tahun 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 ....................................................................………....
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 : .................................................................................................
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 : varises: ya/tidak
 Kebersihan :
 Keputihan :
 Jenis/warna :

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

J. KESIAPAN DALAM KEHAMILAN DAN PERSALINAN:


1. Senam hamil
2. Rencana tempat melahirkan
3. Perlengkapan kebutuhan bayi dan ibu
4. Kesiapan mental ibu dan keluarga
5. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan
proses persalinan

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 TTV DJJ VT
Uterus
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
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

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