FORMAT ASUHAN KEPERAWATAN INTRANATAL

ASUHAN KEPERAWATAN PADA Ny. H…………………

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 :
Pasien datang dengan keluhan sakit perut hilang timbul sejak pukul 09.00 wita
(15 Desember 2017) dan keluar sedikit cairan pervaginam campur darah.

b. Keluhan saat dikaji :

Sakit perut hilang timbul semakin sering dan keluar sedikit cairan
pervaginam campur arah.
 c. Riwayat keluhan (kaji data mulai dari
timbulnya keluhan sampai dengan dilakukan asuhan keperawatan)
Pasien mengatakan sakit perut sejak pukul 09.00 wita (15 Desember 2017).
Kemudian pukul 23.00 pasien mengatakan perutnya semakin sakit. Suami
pasien membawa pasien ke RSUD Wangaya dan di observasi di ruang
ponek.

C. RIWAYAT OBSTETRI DAN GINEKOLOGI

1.Riwayat Menstruarsi :
 Menarche : umur 14 Siklus : teratur ( .) tidak ( )
 Banyaknya :…. Lama : 5 hari
 Keluhan :-
 HPHT :………..

2.Riwayat pernikahan
 Menikah :1.kali Lama : 3 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 :
 G1 P0 A0 H0 UK : 42 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
Pasien berbicara dengan lancar. Pasien menggunakan bahasa Indonesia
dan bahasa kupang dalam berbisara sehari-hari. Pasien tidak
mengalami masalah pada pendengarannya.

Pasien mengeluh nyeri pada bagian perutnya.

P : Pasien mengeluh nyeri semakin hebat saat terjadi kontraksi.
Q : Pasien mengatakan nyeri di perutnya seperti mules
R : Pasien mengatakan nyeri pada bagian perut yang menjalar ke
pinggang
S : Skala nyeri pasien adalah skala 5
T : Pasien mengatakan nyeri yang dirasakan semakin kuat dan semakin
sering dan lama

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

N Tgl / Nomor Rencana Keperawatan

o jam Diagnosa Tujuan Intervensi Rasional
SMART : Tulis NIC
tulis NOC Nursing
yang sesuai activities
disertai
dengan
indicator
capaian
IV. IMPLEMENTASI KALA I
Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
V.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

N Tgl / Nomor Rencana Keperawatan
o jam Diagnosa Tujuan Intervensi Rasional
SMART : Tulis NIC
 tulis NOC Nursing
yang sesuai activities
disertai
dengan
indicator
capaian

D. IMPLEMENTASI KALA II

Tgl/Jam No.Dx Implementasi Respon Paraf/Nama

E. EVALUASI KALA II

Tgl/Jam No Dx Evaluasi Hasil Paraf

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
N Tgl / Nomor Rencana Keperawatan
o jam Diagnosa Tujuan Intervensi Rasional
 SMART : Tulis NIC
tulis NOC Nursing
yang sesuai activities
disertai
dengan
indicator
capaian

3. IMPLEMENTASI KALA III

Tgl/Jam No.Dx Implementasi Respon Paraf/Nama
4. EVALUASI KALA III
 Tgl/Jam No Dx Evaluasi Hasil Paraf/Nama

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/Jam No Dx Evaluasi Hasil Paraf/Nama
Denpasar, …………………….20…..
 Mengetahui
Pembimbing Klinik/ CI Mahasiswa

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

Clinical Teacher/CT 1

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

NIP: