FORMAT ASUHAN KEPERAWATAN INTRANATAL

ASUHAN KEPERAWATAN PADA Ny…………………

DENGAN……………………………………...................
DI RUANG …………………………………...................
RS……………...........................................................
TANGGAL ………………….......................................
I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :
Umur :
Pendidikan :
Pekerjaan :
Status Perkawinan :
Agama :
Suku :
Alamat :
No CM :
Tanggal MRS :
Tanggal Pengkajian :
Sumber informasi :
Penanggung Jawab
Nama :
Umur :
Pendidikan :
Jenis kelamin :
Pekerjaan :
Alamat :
Status perkawinan :
Agama :
B. DATA KESEHATAN
a. Keluhan Utama :

b. Keluhan saat dikaji :

 c. Riwayat keluhan (kaji data mulai dari
timbulnya keluhan sampai dengan dilakukan asuhan keperawatan)

C. RIWAYAT OBSTETRI DAN GINEKOLOGI

1.Riwayat Menstruarsi :
 Menarche : umur ….. Siklus : teratur ( ) tidak ( )
 Banyaknya :…. Lama :………
 Keluhan :………
 HPHT :………..

2.Riwayat pernikahan
 Menikah : ….kali Lama : ….tahun

3. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak Kehamilan Persalinan Komplikasi nifas Anak
Ke
N T Umur Peny je penol Peny Lase infe Perdar Jenis B P
o h keham ulit nis ong ulit rasi ksi ahan Kela B j
n ilan min

4. Riwayat kehamilan saat ini

Status Obstetrikus :
 G…P…A…H… UK : ……..minggu
 TP : ….
 ANC kehamilan sekarang :………...........................................
Trimester I :…………………………………………………………

Trimester II : …………………………………………………….....

Trimester III : ……………………………………………………....

5. Riwayat keluarga berencana
 Akseptor KB : …...
 Jenis :……
 Lama :………
 Masalah : ……

C. RIWAYAT PENYAKIT
1. Klien :…………

2. Keluarga : …………

E. POLA FUNGSIONAL KESEHATAN

1. Pola Manajemen Kesehatan-Persepsi Kesehatan
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2. Pola Metabolik-Nutrisi
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3. Pola Eleminasi
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 4. Pola Aktivitas-Latihan

SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4
Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah

Tabel 1. Kemampuan perawatan diri

Skor 0 = mandiri 3 = dibantu orang lain &alat

1 = alatbantu 4 = tergantung/tidakmampu
2 = dibantu orang lain

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5. Pola Istirahat-Tidur
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6. Pola Persepsi-Kognitif
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7. Pola Konsep Diri-Persepsi Diri

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8. Pola Hubungan-Peran
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9. Pola Reproduktif-Seksualitas
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10. Pola Toleransi Terhadap Stres-Koping

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11. Pola Keyakinan-Nilai

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F.PEMERIKSAAN FISIK
Keadaan umum :
 GCS : E..…….....….V.....................M...................
 Tingkat kesadaran : ………………….........................................
 Tanda – tanda vital : TD….............N….........RR….........T…......
 BB : ………….TB:………… LILA :………..
Head toe toe :
 Kepala

wajah :

Pucat ( )

Cloasma ( )

sklera :

konjungtiva :

pembesaran limphe node

pembesaran kelenjar tiroid :

telinga : ………………………………………

 Dada

Payudara

Areola :……………..

Putting : (menonjol / tidak )

Tanda dimpling / retraksi :…………………

Pengeluaran ASI : ………………..

Jantung : ……….

Paru : …………..

 Abdomen
Linea : ……

Striae :…………

Pembesaran sesuai UK : ………….

 Gerakan Janin : …………..

Kontraksi : …….

Luka bekas operasi : …………..

Ballottement : ……………………….
Leopold I : Kepala / bokong / kosong TFU:…….............
Leopold II : Kanan : punggung/bagian kecil/bokong /kepala
Kiri : punggung / bagian kecil /bokong/kepala
Leopold III : Presentasi kepala / bokong/kosong
Leopold IV : Bagian masuk PAP (konvergen/divergen/sejajar)
Penurunan kepala : .........(penurunan bag.terbawah dengan metode lima
jari )
Kontraksi : ………………….
DJJ :…………………..
Bising usus : …………………..
 Genetalia dan perineum :

Kebersihan :……………

Pengeluaran :………………….

Karakteristik :……………..

Hasil VT : …………………………………………………………
  Ekstremitas

Atas

Oedema :………………....................................................…

Varises :…………………....................................................

CRT :…………………....................................................

Bawah

Oedema :…………………....................................................

Varises :…………………....................................................

CRT :…………………....................................................

Refleks :……………….......................................................

G.DATA PENUNJANG
 Pemeriksaan Laboratorium :………………………..
  Pemeriksaan USG :………………………..

H.DIAGNOSA MEDIS

I.PENGOBATAN
KALA I
1. ANALISA DATA KALA I
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
 1. ..............................................................................................
2. ..............................................................................................
3. ..............................................................................................
4. ..............................................................................................
5. ..............................................................................................

II. RENCANA KEPERAWATAN KALA I

No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
III. IMPLEMENTASI KALA I
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
IV. EVALUASI KALA I
 Tgl/Jam No Dx Evaluasi Hasil Paraf

KALA II
A. DATA FOKUS KALA II
B. ANALISA DATA KALA II
DATA FOKUS ANALISIS MASALAH
 Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
 2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................

C. RENCANA KEPERAWATAN KALA II

No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
D. IMPLEMENTASI KALA II

Tgl/Jam No.Dx Implementasi Respon Paraf/Nama

E. EVALUASI KALA II
Tgl/Ja No Dx Evaluasi Hasil Paraf
m
KALA III
A. DATA FOKUS KALA III

B. ANALISA DATA KALA III

DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas :
 1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................
5. ...........................................................................................

2. RENCANA KEPERAWATAN KALA III

No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
3. IMPLEMENTASI KALA III
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
4. EVALUASI KALA III
Tgl/Ja No Dx Evaluasi Hasil Paraf/Nama
m
KALA IV
A. DATA FOKUS KALA IV

B. ANALISA DATA KALA IV

DATA FOKUS ANALISIS MASALAH
 Diagnosa keperawatan berdasarkan prioritas :
1. ...........................................................................................
2. ...........................................................................................
3. ...........................................................................................
4. ...........................................................................................

C.RENCANA KEPERAWATAN KALA IV

No Tgl / Nomor Rencana Keperawatan
jam Diagnosa Tujuan Intervensi Rasional
D. IMPLEMENTASI KALA IV
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
E.EVALUASI KALA IV
Tgl/Ja No Dx Evaluasi Hasil Paraf/Nama
m
 Denpasar, …………………….20…..

Mengetahui
Pembimbing Klinik/ CI Mahasiswa

(....................................................) (.......................................................)
NIP: NIM:

Clinical Teacher/CT 1

(……..…………….....................................................)

NIP: