POLTEKNIK KESEHATAN KEMENKES BANDUNG

PROGRAM STUDI KEBIDANAN KARAWANG

Jalan Kertabummi No. 74

FORMAT PENGKAJIAN INTRANATAL CARE

No. Register : Tanggal/Waktu Pengkajian :

Nama Pengkaji : Tempat Pengkajian :

I. PENGKAJIAN DATA SUBJEKTIF (S)

A. Biodata
Nama Klien : Nama Suami :
Umur : Umur :
Agama : Agama :
Suku bangsa : Suku bangsa :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Golongan darah : Golongan darah :
Alamat rumah : Alamat rumah :
Satus perkawinan : Satus perkawinan :
No. telepon : No. telepon :

B. KELUHAN
......................................................................................................................................................................
......................................................................................................................................................................

C. RIWAYAT KEHAMILAN SEKARANG

Kehamilan ke : ............... Bersalin : ............... Kali Keguguran : ............... Kali
HPHT : .......................... Taksiran Persalinan : ............... Usia Kehamilan : ............... minggu
Siklus haid : ........... hari Lamanya Haid : ............ hari, Teratur/Tidak teratur
Dismenorrhea : Ada/Tidak Banyaknya : ........... kali ganti pembalut/hari
Gerakan janin yang dirasakan dalam 24 jam terakhir : .................... kali, Kuat/Tidak
Imunisasi TT1 tanggal : .......................... Tempat : ..........................
Imunisasi TT2 tanggal : .......................... Tempat : ..........................
Periksa Kehamilan : ........... Kali Tempat : ...................... Oleh : ......................
Tablet Fe : .......... Tablet, Habis/Sisa Cara minum : ...................................................................

D. RIWAYAT KEHAMILAN DAN PERSALINAN YANG LALU

Persalinan Nifas Ke
No Usia J
Tahun Penolon Jenis BB PB Loche Laktas
. Kehamilan K Tempat H/M Infeksi
g a i

E. POLA AKTIVITAS SEHARI-HARI

1. Diet
a. Nutrisi
1) Terakhir kali makan : ...............................................................................
2) Jenis makanan yang dikonsumsi : ...............................................................................
3) Makanan yang dipantang : ...............................................................................
4) Alergi terhadap makanan : ...............................................................................
b. Hidrasi
1) Terakhir kali minum : ...............................................................................
2) Jenis minuman : ...............................................................................
 2. Istirahat dan Tidur
a. Malam : ................................ jam/hari
b. Siang : ................................ jam/hari
c. Masalah : ..............................................
3. Personal Hygiene
a. Mandi : ................................ x/hari
b. Gosok Gigi : ................................ x/hari
c. Ganti pakaian : ................................ x/hari
4. Aktivitas Seksual
Kapan hubungan seksual terakhir : ...............................................................................
Keluhan/masalah : ...............................................................................
5. Eliminasi
a. BAK
Terakhir kali BAK : ...............................................................................
Banyaknya : ...............................................................................
Keluhan : ...............................................................................
b. BAB
Terakhir kali BAB : ...............................................................................
Konsistensi : ...............................................................................
Banyaknya : ...............................................................................
Keluhan : ...............................................................................

F. RIWAYAT KESEHATAN
1. Riwayat penyakit yang sedang/pernah diderita
Hipertensi : ............... Hepatitis B : .............. TBC : .............. Thypus Abdominalis : ...............
PMS : ........................ Lain-lain : ......................
2. Riwayat penyakit keluarga
Hipertensi : ............... DM : ........................... Ashma : ............. Lain-lain : ...................................
3. Riwayat alergi: ...............................................
4. Perilaku Kesehatan
a. Penggunaan alkohol/obat-obatan sejenis : ya/tidak
Jenisnya : ...............................................................................
Banyaknya : ...............................................................................
Waktu mengkonsumsi : ...............................................................................
b. Obat-obatan/jamu yang sering dikonsumsi : ada/tidak
Jenisnya : ...............................................................................
Banyaknya : ...............................................................................
Waktu mengkonsumsi : ...............................................................................
c. Merokok : ya/tidak
Jenisnya : ...............................................................................
Banyaknya : ...............................................................................
Waktu mengkonsumsi : ...............................................................................

G. RIWAYAT SOSIAL
Kehamilan ini diinginkan atau direncanakan : Ya/Tidak
Status Perkawinan : ..................................................
Pernikahan ke : .................... Lamanya : ................ tahun
Hubungan klien dengan suami : ...............................................................
Hubungan klien dengan anggota keluarga lain : ......................................................
Pengambilan keputusan dalam keluarga : ......................
Pendamping persalinan : ....................................................................
Dukungan keluarga : ........................................................................
Pendodonor darah : ...........................................................................
Rencana menyusui : ...........................................................................
Keluarga yang tinggal serumah

No. Nama L/P Usia Hubungan Keluarga Pendidikan Pekerjaan Ket.

II. PENGKAJIAN DATA OBJEKTIF (O)
A. Keadaan Umum : ....................... Kesadaran : ............................. Status Emosional : .....................
B. Tanda-tanda vital
Tekanan Darah : ............. mmHg Nadi : ............ kali/menit, regular/irregular
Respirasi : .............kali/menit, regular/irregular Suhu : ........... oC
C. Tinggi badan : ....................... cm
Berat badan sekarang : ....................... Kg
Berat badan sebelum hamil : ....................... Kg
Kenaikan berat badan : ....................... Kg
Lingkar Lengan : ....................... cm
D. Pemeriksaan Fisik
1. Kepala
Inspeksi
a. Warna rambut : ...............................................................................
b. Kebersihan : ...............................................................................
Palpasi
a. Keadaan rambut : rontok/tidak
b. Benjolan : ada/tidak
2. Muka
Inspeksi
a. Oedema : ...............................................................................
b. Pucat atau tidak : ...............................................................................
Palpasi
a. Oedema : ...............................................................................
3. Mata
Inspeksi
a. Konjungtiva : ...............................................................................
b. Sklera : ...............................................................................
4. Hidung
a. Kebersihan : ...............................................................................
b. Pengeluaran : ...............................................................................
c. Polip : ...............................................................................
5. Telinga
a. Kebersihan : ...............................................................................
b. Pengeluaran : ...............................................................................
c. Fungsi pendengaran : ...............................................................................
6. Bibir
Inspeksi
a. Pucat : ...............................................................................
b. Stomatitis : ...............................................................................
7. Gigi
a. Caries : ...............................................................................
b. Gigi palsu : ...............................................................................
8. Lidah
a. Warna : ...............................................................................
9. Leher
a. Pembengkakan kelenjar thyroid : ...............................................................................
b. Pembengkakan KGB : ...............................................................................
c. Pembengkakan vena jugularis : ...............................................................................
10. Dada
 Payudara
Inspeksi
a. Bentuk : ...............................................................................
b. Kebersihan : ...............................................................................
c. Benjolan : ...............................................................................
d. Puting susu : ...............................................................................
e. Hyperpigmentasi : ...............................................................................
f. Retraksi/dimpling : ...............................................................................
g. Lecet : ...............................................................................
Palpasi
a. Benjolan : ...............................................................................
b. Colostrum : ...............................................................................
c. Pembesaran KGB Axila : ...............................................................................
Jantung
a. Irama : ......................... Gallop : .................................. Mur-mur : ...............................
Paru-paru
b. Bunyi : ........................ Ronchii : ............................... Wheezing : ..............................
11. Abdomen
Inspeksi
a. Bentuk perut : ...............................................................................
b. Sikatrik bekas operasi : ...............................................................................
c. Striae : ...............................................................................
d. Hyperpigmentasi : ...............................................................................
Palpasi
a. TFU :
b. Leopold I : ........................................................................................................................
c. Leopold II : ........................................................................................................................
........................................................................................................................
d. Leopold III : ........................................................................................................................
e. Leopold IV : ........................................................................................................................
f. Perlimaan : ........................................................................................................................
g. TBJ : ........................................................................................................................
h. Penilaian His
Frekuensi : ...... x/10 menit Interval his : .......... Durasi his : ...... detik Intensitas : .........
Auskultasi
a. DJJ
Frekuensi : .............. x/menit Kekuatan : .............. Regularitas : ..............
12. Ekstremitas
Ekstremitas atas
Inspeksi
a. Oedema : Ya/Tidak
b. Kuku : Bersih/Tidak, Panjang/Pendek
Pelapasi
a. Oedema : Ya/Tidak
b. Capillary refill : ...............................................................................
Ekstremitas bawah
Inspeksi
a. Bentuk : ...............................................................................
b. Oedema : ...............................................................................
c. Varises : ...............................................................................
Palpasi
a. Oedema : ...............................................................................
b. Capillary refill : ...............................................................................
c. Varises : ...............................................................................
Perkusi
a. Reflex patella : ...............................................................................
13. Genetalia
Inspeksi
 a. Oedema : ...............................................................................
b. Varises : ...............................................................................
c. Pembesaran kelenjar bartholin : ...............................................................................
d. Pengeluaran : ...............................................................................
e. Tanda Infeksi : ...............................................................................
Pemeriksaan Dalam
a. Vulva/vagina : ..............................................................................................
b. Portio : ..............................................................................................
c. Pembukaan serviks : ..............................................................................................
d. Keadaan ketuban : ..............................................................................................
e. Presentasi : ..............................................................................................
f. Denominator : ..............................................................................................
g. Molage : ..............................................................................................
h. Turunan bagian terendah : ..............................................................................................
i. Bagian lain yang teraba : ..............................................................................................

14. Anus
Inspeksi
a. Haemorroid : ...............................................................................
E. Pemeriksaan Laboratorium
1. Darah : Hb : ............... gr%
Urine : Protein : .............................................................
Glukosa : .............................................................

III. ASSESMENT (A)

Diagnosa : ...........................................................................................................
.......................................................................................................................................................................
Masalah potensial : ...........................................................................................................
Antisipasi masalah potensial : ...........................................................................................................

IV. PLANNING (P)

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KALA II

Hari/Tanggal : ............................................................. Jam : ................................................

I. PENGKAJIAN DATA SUBJEKTIF (S)

Keluhan : ..................................................................................................................................................
......................................................................................................................................................................
II. DATA OBJEKTIF (O)
1. Keadaan Umum
a. Kesadaran : ..........................................................................
b. Keadaan Umum : ..........................................................................
c. Status Emosional : ..........................................................................
2. Tanda-tanda vital
a. Tekanan darah : ............................................................. mmHg
b. Nadi : ............................................................. x/menit
c. Respirasi : ............................................................. x/menit
d. Suhu : ............................................................. oC
3. HIS
a. Intensitas : .............................................................
b. Frekuensi : ............................................................. x/10 menit
c. Interval : ............................................................. menit
d. Durasi : ............................................................. detik
4. DJJ
a. Frekuensi : ............................................................. x/menit, Regular/Irregular
5. Pemeriksaan Luar Andomen
a. Perlimaan : .............................................................
b. Vesika Urinaria : .............................................................
6. Pemeriksaan Dalam
a. Vulva/vagina : ...........................................................................................................
b. Portio : ...........................................................................................................
c. Pembukaan serviks : ...........................................................................................................
d. Keadaan ketuban : ...........................................................................................................
e. Presentasi : ...........................................................................................................
f. Denominator : ...........................................................................................................
g. Molage : ...........................................................................................................
h. Turunan bagian terendah : ...........................................................................................................
i. Bagian lain yang teraba : ...........................................................................................................

III. ASSESMENT (A)

Diagnosa : ...........................................................................................................
......................................................................................................................................................................
Masalah potensial : ...........................................................................................................
Antisipasi masalah potensial : ...........................................................................................................

IV. PLANNING (P)

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KALA III

Hari/Tanggal : ............................................................. Jam : ................................................

I. PENGKAJIAN DATA SUBJEKTIF (S)

Keluhan : ..................................................................................................................................................
......................................................................................................................................................................
II. DATA OBJEKTIF (O)
1. Keadaan Umum
a. Kesadaran : ..........................................................................
b. Keadaan Umum : ..........................................................................
c. Status Emosional : ..........................................................................
2. Tanda-tanda vital
a. Tekanan darah : ............................................................. mmHg
b. Nadi : ............................................................. x/menit
 c. Respirasi : ............................................................. x/menit
d. Suhu : ............................................................. oC
3. Abdomen
a. Tinggi Fundus : ...........................................................................................................
b. Kontraksi : ...........................................................................................................
c. Bayi ke-2 : ...........................................................................................................
4. Keadaan Kandung kemih : ...........................................................................................................
5. Tanda-tanda elepasan plasenta
a. Tali pusat memanjang : ...........................................................................................................
b. Uterus membulat : ...........................................................................................................
c. Semburan darah tiba-tiba : ...........................................................................................................
III. ASSESMENT (A)
Diagnosa : ...........................................................................................................
......................................................................................................................................................................
Masalah potensial : ...........................................................................................................
Antisipasi masalah potensial : ...........................................................................................................

IV. PLANNING (P)

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Waktu Plasenta Lahir
a. Keadaan Plasenta
Kotiledon : ........................................................................................................................
Selaput ketuban : ........................................................................................................................
Insersi tali pusat : ........................................................................................................................
Diameter : ........................................................................................................................
Tebal : ........................................................................................................................
Panjang tali pusat : ........................................................................................................................
Infark dan kelainan : ........................................................................................................................
b. Perdarahan : ........................................................................................................................
c. Kontraksi : ........................................................................................................................
Konsistensi : ........................................................................................................................
Intensitas : ........................................................................................................................
 KALA IV

Hari/Tanggal : ............................................................. Jam : ................................................

I. PENGKAJIAN DATA SUBJEKTIF (S)

Keluhan : ..................................................................................................................................................
......................................................................................................................................................................
II. DATA OBJEKTIF (O)
1. Keadaan Umum
a. Kesadaran : ..........................................................................
b. Keadaan Umum : ..........................................................................
c. Status Emosional : ..........................................................................
2. Tanda-tanda vital
a. Tekanan darah : ............................................................. mmHg
b. Nadi : ............................................................. x/menit
c. Respirasi : ............................................................. x/menit
d. Suhu : ............................................................. oC
3. TFU : ..........................................................................
4. Keadaan Vesika Urinaria : ..........................................................................
5. Jumlah perdarahan : ..........................................................................
6. Laserasi jalan lahir : ..........................................................................

III. ASSESMENT (A)

Diagnosa : ...........................................................................................................
......................................................................................................................................................................
Masalah potensial : ...........................................................................................................
Antisipasi masalah potensial : ...........................................................................................................

IV. PLANNING (P)

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