FORMAT PENGKAJIAN INTRANATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

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 ..................................................

STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
.............................................................................................................................................

.…………………………

2. Keluhan utama saat ini : ..................................................................

…….....................................................................................................................................

...........................

…………………………………………………………………………………….……

3. Riwayat Persalinan saat ini

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

RIWAYAT KEPERAWATAN

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

b. Riwayat kehamilan, persalinan, nifas :

Ana Kehami
Persalinan Komplikasi nifas Anak
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB pj
o long ksi han
u a ulit ulit si
n m
il
a
n

Genogram

Riwayat keluarga berencana :

Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................
Riwayat kesehatan :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

Riwayat lingkungan :
- Kebersihan : ...........................................................................................................
…………….......
- Bahaya :
…………......................................................................................................................
- Lainnya sebutkan : .................................................................................
…………………….....................

Aspek psikososial :
Persepsi ibu tentang keluhan/ penyakit : ................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ? ............
Bila ya bagaimana ..................................................................................................
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak

Kebutuhan dasar khusus (Di rumah dan di rs) :

Pola Nutrisi
Frekwensi makan : .............................. x sehari
Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : ................................................................................….
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : .......................……………………………………………….
Keluhan saat BAK : .................................................………......................

BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : .............……………………………………………….........
 Keluhan ....................................................................………....
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
Ketergantungan obat
: ..............................................................................................
Pemeriksaan fisik
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : .....................................Suhu : .......…........C
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
 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 : ...........................................................................................

Kesiapan dalam kehamilan dan persalinan:

Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan
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

Data Penunjang
1) Laboratorium
: .................................................................................................
2) USG
: .................................................................................................
3) Rontgen : .................................................................................
................
4) Terapi yang
didapat: ..............................................................................................................................
......................................................

Data Tambahan
................................................................................................................................................
..........................................
Surabaya, ........................................
Pemeriksa
 (..................................................)

ANALISA DATA

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................

No Data Penyebab Masalah

1. Ds.

Do.

2. Ds
 Do.

3. Ds.

Do.

4. Ds.

Do.

5. Ds.

Do.

dst
PRIORITAS MASALAH

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................

TANGGAL Nama
No Diagnosa keperawatan
ditemukan Teratasi perawat
 RENCANA KEPERAWATAN

Nama Klien :...................... No Rekam Medis :....................... Hari Rawat Ke :............

No Diagnosa keperawatan Tujuan Rencana Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

NAMA KLIEN : Ruangan / kamar : ......../.........

UMUR : No. Register :...............................
No Tgl Tindakan TT Tgl Catatan Perkembangan TT
Dx Jam Perawat Jam Perawat
Dx 1 :
S.
O

A
P
Dx. 2 :
S.
O

A
P
Dx 3 :.......
S.
O

A
P
Dx 4 :.......
S.
O

A
P

dst