Nama Mahasiswa : Yeheskel Y.

Slarmanat Nim : 711 490 119 028

PENGKAJIAN INTRANATAL

I. DATA UMUM
Inisial Klien : ..................... Nama suami : ..........................
Umur : ..................... Umur : ..........................
Alamat : ..................... Pekerjaan : ..........................
Pekerjaan : ..................... Pendidikan terakhir : ..........................
Pendidikan : .....................
Agama : .....................
Suku bangsa : .....................
Status perkawinan : .....................
Pendidikan terakhir : .....................
Ruangan : .....................
No. MR : .....................
Tgl Masuk : ......................
Tgl /Jam Pengkajian : ......................

II. DATA UMUM KESEHATAN

1. Tinggi badan/berat badan : ................................................
2. Berat badan sebelum hamil : ................................................
3. Masalah kesehatan khusus
: ...........................................................................................................................................................
.........................................................................................................................................................................
..............
4. Obat-obatan
: ...........................................................................................................................................................
.........................................................................................................................................................................
..............
5. Alergi(obat/makanan/bahan tertentu) : ...............................................................................................
6. Diet khusus : ................................................
7. Menggunakan : gigi palsu/kaca mata/lensa kontak/alat pndengar)
8. Lain-lain sebutkan : ...............................................................................................
9. Frekuensi BAK
: ...........................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.............
Masalah (ada/tidak) : jika ada,
jelaskan ...........................................................................................................................................................
.........................................................................................................................................................................
..............
10. Frekuensi BAB
: ...........................................................................................................................................................
 .........................................................................................................................................................................
.........................................................................................................................................................................
..............
Masalah (ada/tidak) : jika ada, jelaskan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11. Kebiasaan waktu tidur
: ...........................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
..............

DATA UMUM
1. Kehamilan sekarang direncanakan (ya/tidak) : ...................................................................................
2. Status obstretikus : G... P... A...Usia................. kehamilan...................minggu
3. HPHT : .....................................Taksiran partus....................................
4. Jumlah anak di rumah

No. Jenis Cara Lahir BB lahir Keadaan Umur

1.
2.
3.
4.
5.
6.

5. Mengikuti kelas prenatal : (ya/tidak)

6. Jumlah kunjungan pada kehamilan ini : ...............................................................................................
7. Masalah kehamilan yang lalu : ...............................................................................................
8. Masalah kehamilan sekarang : ...............................................................................................
9. Rencana KB : ...............................................................................................
10. Makanan bayi sebelumnya : ASI/PASI/lain-lain ...............................................................
11. Pelajaran apa yang diinginkan saat ini : (lingkari) relaksasi, pernapasan/manfaat ASI/cara memberi
minum botol/senam nifas/Metode KB/Perawatan perineum/Perawatan payudara.
12. Setelah bayi lahir, siapa yang diharapkan membantu : suami/teman/orang tua*)
13. Masalah dalam persalinan
lalu : ................................................................................................................................................................
.........................................................................................................................................................................
.........

III. RIWAYAT PERSALINAN SEKARANG

1. Mulai persalinan (kontraksi/pengeluaran pervaginam): Tgl/Jam ...................................................................
2. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya,
kekuatan) : ......................................................................................................................................................
 .........................................................................................................................................................................
...................
3. Frekuensi dan kualitas denyut jantung janin : ................................X/menit.
4. Pemeriksaan fisik :
Kenaikan BB selama kehamilan : .............................. kg
Tanda vital : TD : ....................mmHg, N : ..........X/mnt, SB : ........°C, RR :.........X/mnt
Kepala dan leher (normal/tidak) : ...................................................................................................................
Jantung : .........................................................................................................................................................
................
.........................................................................................................................................................................
Paru-
paru : ...............................................................................................................................................................
..........
.........................................................................................................................................................................
Payudara : .......................................................................................................................................................
..................
.........................................................................................................................................................................
Abdomen (secara umum dan pemeriksaan
obstetric) : .......................................................................................................................................................
..................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Kontraksi : ................................................... DJJ : ............................................
Ekstremitas :
(edema/tidak) ..................................................................................................................................................
.......................
.........................................................................................................................................................................
5. Pemeriksaan dalam pertama : jam .......................... Oleh .................................
Hasil : .............................................................................................................................................................
............
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Ketuban (utuh/pecah*). Jika sudah pecah tgl/jam …………….warna………......
7. Laboratorium :
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
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 .........................................................................................................................................................................

IV. DATA PSIKOSOSIAL

1. Penghasilan keluarga tiap bulan : Rp……………………………………
2. Bagaimana perasaan anda terhadap kehamilan sekarang
………………………………………………………………………………………………………….........
.........................................................................................................................................................................
……………………………………………………………………………………………………………….
3. Bagaimana perasaan suami terhadap kehamilan sekarang
……………….................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. Jelaskan respon sibling terhadap kehamilan
sekarang ..........................................................................................................................................................
...............
.........................................................................................................................................................................
.........................................................................................................................................................................

LAPORAN PERSALINAN

I. PENGKAJIAN AWAL
1. Tanggal : Jam :
2. Tanda-tanda vital : TD : mmHg, N : x/mnt, SB : °C, RR : x/mnt
3. Pemeriksaan palpasi abdomen :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. Hasil periksa dalam :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5. Pengeluaran pervaginam :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Perdarahan pervaginam :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7. Kontraksi uterus ( frekuensi, lamanya, kekuatan ) :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
8. DJJ ( frekuensi, kualitas ) :
.........................................................................................................................................................................
.........................................................................................................................................................................
9. Status janin ( hidup/mati, jumlah, presentasi ) :
 .........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
II. KALA PERSALINAN
⮚ KALA I
1. Mulai persalinan : Tgl : Jam :
2. Tanda dan gejala :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
3. Tanda – tanda vital : TD : mmHg, N : x/mnt, SB : °C, RR : x/mnt
4. Lama kala 1 : jam menit detik
5. Keadaan psikososial :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
6. Kebutuhan khusus klien :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
7. Tindakan :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
8. Pengobatan :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................

OBSERVASI KEMAJUAN PERSALINAN

Tanggal/jam Kontraksi Uterus DJJ Keterangan

⮚ KALA II
1. Kala II mulai : Tgl : Jam :
2. Lama kala II : jam menit detik
3. Tanda dan gejala :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. Jelaskan upaya meneran :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5. Keadaan psikososial :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Tindakan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

CATATAN KELAHIRAN

1. Bayi lahir jam :

.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
2. Nilai APGAR : Menit 1 Menit 5
3. Perineum : ( ) utuh, ( ) episiotomi, ( ) ruptur, tingkat
4. Bonding atemen :
.........................................................................................................................................................................
.........................................................................................................................................................................
 .........................................................................................................................................................................
5. Tanda-tanda vital : TD : mmHg, N : x/mnt, SB : °C, RR : x/mnt
6. Pengobatan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

⮚ KALA III
1. Tanda dan gejala :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
2. Placenta lahir jam :
........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
3. Cara lahir placenta
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. Karakteristik placenta :
● Ukuran : cm
● Panjang tali pusat: cm
● Pembulu darah : arteri, vena
● Kelainan :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
5. Perdarahan : cc,
Karakteristik ...................................................................................................................................................
......................
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Keadaan psikososial
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7. Tindakan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
8. Pengobatan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

⮚ KALA IV
 1. Mulai jam :
2. Tanda-tanda vital : TD : mmHg, N : x/mnt, SB : °C, RR : x/mnt
3. Keadaan uterus :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. Perdarahan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5. Bonding attetmen :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Tindakan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

⮚ BAYI
1. Bayi lahir tanggal / jam :
2. Jenis kelamin :
3. Nilai APGAR :
4. BB / PB :
5. Karakteristik bayi
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6. Lingkar kepala :
7. Kaput suksadaneum : ( ), Cephal hematom ( )
0
8. Suhu : c
9. Anus : berlubang / tertutup
10. Perawatan tali pusat :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................