FORMAT ASUHAN KEPERAWATAN INTRANATAL Baru
FORMAT ASUHAN KEPERAWATAN INTRANATAL Baru
2.Riwayat pernikahan
Menikah : ….kali Lama : ….tahun
Trimester II : …………………………………………………….....
C. RIWAYAT PENYAKIT
1. Klien :…………
2. Keluarga : …………
2. Pola Metabolik-Nutrisi
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3. Pola Eleminasi
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4. Pola Aktivitas-Latihan
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5. Pola Istirahat-Tidur
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6. Pola Persepsi-Kognitif
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9. Pola Reproduktif-Seksualitas
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wajah :
Pucat ( )
Cloasma ( )
sklera :
konjungtiva :
telinga : ………………………………………
Dada
Payudara
Areola :……………..
Jantung : ……….
Paru : …………..
Abdomen
Linea : ……
Striae :…………
Kontraksi : …….
Ballottement : ……………………….
Kontraksi : ………………….
DJJ :…………………..
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
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2. ................................................................................................................................................
3. ................................................................................................................................................
4. ................................................................................................................................................
5. ................................................................................................................................................
II. RENCANA KEPERAWATAN KALA I
KALA II
A. DATA FOKUS KALA II
B. ANALISA DATA KALA II
DATA FOKUS ANALISIS MASALAH
2. .....................................................................................................................................
3. .....................................................................................................................................
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5. ......................................................................................................................................
Mengetahui
Pembimbing Klinik/ CI Mahasiswa
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NIP: NIM:
Clinical Teacher/CT 1
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NIP: