FORMAT PENGKAJIAN INTRA NATAL

MATA AJAR KEPERAWATAN REPRODUKSI

PROGRAM STUDI NERS
UNIVERSITAS MUHAMMADIYAH KALIMANTAN TIMUR
JL. Ir. H.Juanda No. 15 telp : (0541)748511 SAMARINDA

Nama Mahasiswa : ……………………………………………………………

NIM : ……………........................................................................
Tanggal Pengkajian : ……………………………………………………………
Rumah Sakit/ Ruang :......................................................................................

I. DATA UMUM KLIEN

1. Initial Klien : …………………………………………………………..

2. Usia
3. Status Perkawinan
4. Pernikahan Ke
5. Lama perkawinan
6. Pekerjaan
7. Pendidikan Terakhir
8. Inisial Suami
9. Usia
10. Pendidikan
11. Pekerjaan (Spesifik)
12. Suku/ Bangsa
13. Pernikahan ke
14. Alamat
: …………………………………………………………..
: …………………………………………………………...
:...............................................................................
: .....................................................................................
: …………………………………………………………….
: …………………………………………………………….
:…………………………………………………………….
:…………………………………………………………….
:....................................................................................
: .................................................................................
:……………………………………………………………
: .................................................................................
:……………………………………………………………

II. DATA UMUM KESEHATAN

1. TB/ BB : ......cm/.......kg
2. BB sebelum hamil : .................Kg
3. Masalah Kesehatan Khusus:

4. Obat-obatan yang diterima saat ini:

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 5. Alergi (obat/ makanan/ bahan tertentu):
6. Diet Khusus :
7. Alat bantu yang digunakan:
 Gigi palsu :
 Kaca mata/ lensa kontak :
 Alat dengar :
 Lain-lain :
8. Frekuensi BAK: ................. masalah: ...............................................................
Frekuensi BAK menjelang persalinan: .................................
9. Frekuensi BAB, ........................................masalah:................................................
Frekuensi BAB menjelang persalinan: ..........................................................
10. Kebiasaan waktu tidur:
Kebiasaan tidur menjelang persalinan

III. DATA UMUM OBSTETRI

1. Kehamilan sekarang direncanakan: ya / tidak

Alasannya:
2. Status Obstetrik : G .....P......A......
3. HPHT: ........................................TP: ..............................
4. Jumlah anak:

No Jenis Cara Lahir BB L Keadaan Umur

Kelamin

5. Mengikuti kelas prenatal: ya/ tidak

6. Jumlah kunjungan ANC pada kehamilan ini:
Hambatan dalam ANC:
7. Masalah kehamilan yang dulu
8. Masalah kehamilan sekarang;
Upaya yang dilakukan untuk mengatasi:
9. Rencana KB setelah persalinan:
10. Makanan bayi sebelumnya:
- ASI : ya/ tidak , berapa lama:
- PASI: ya/ tidak, sejak usia bayi:

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 11. Pelajaran bayi yang diinginkan saat ini:
- Relaksasi/ pernafasan:
- Managemen nyeri non farmakologi:
- Manfaat ASI
- IMD
- Metode KB
- Perawatan perineum
- Perawatan payudara
- Perawatan BBL
- Lain-lain: jelaskan:
12. Setelah bayi lahir, siapa yang diinginkan untuk membantu merawata bayi:
suami/ orang tua/ mertua/ teman/ tenaga kesehatan
Alasan:
13. Masalah dalam persalinan sebelumnya”

IV. RIWAYAT PERSALINAN SEKARANG

14. Mulai persalinan (kontraksi/ pengeluaran pervaginam)

Tgl/jam:
15. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan):
16. Frekuensi, kualitas dan keteraturan DJJ:
17. Pemeriksaan Fisik:
- Kenaikan BB selama kehamilan: ........................kg
- Tanda Vital: TD:............mmHg; N:........x/mnt; RR:...........x/mnt; suhu: ....... oC
- Kepala dan leher:
a. Bentuk :……………………………………………
b. Konjungtiva :-------------------------------------
c. Sklera : ------------------------------------
d. Edema palpebra :-------------------------------------
e. Pandangan kabur :-------------------------------------
f. Pupil :-------------------------------------
g. Pembesaran kelenjar tyroid :-------------------------------------
h. Pembesaran kelenjar getah bening :-------------------------------------
i. Kesulitan menelan :------------------------------------
j. Keluhan lain :-----------------------------------
- Dada dan axilla
a. Mammae : membesar :ya/ tidak
b. Perubahan kontour kulit pd payudara :-------------------------------------
c. Areolla mamae : …………………………………………….
d. ASI/Nanah/Darah :……………………………………………..
e. Pembesaran KGB di axila :---------------------------------------
f. Sesak nafas :--------------------------------------
g. Retraksi dinding dada :---------------------------------------

- Abdomen
a. Tinggi Fundus Uteri :……………………………………………
b. Lingkar abdomen :--------------cm
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 c. Linea dan striae :…………………………………………….
d. Hiperpigmentasi :--------------------------------------
e. Luka bekas operasi / jenis :…………………………/………………….
f. Kontraksi :…………………………………………….
g. Teraba massa: ya/tidak, jika ya di daerah:------------------------------
h. Distensi abdomen :-------------------------------------
i. Bising Usus :-------------------------------------
j. Lainnya sebutkan :…………………………………………….
- Genitourinary
a. Area genital bersih :----------------------------------------
b. Ada discharge : ya / tidak; jenis :----------------------------------------
c. Ada perdarahan antara fase menstruasi :---------------------------------------
d. Perdarahan pasca coitus :------------------------------------------
e. Vesika urinary penuh :…………………………………………….
f. Rangsang miksi menurun :---------------------------------------
g. Nyeri saat miksi :---------------------------------------
h. Miksi tidak tuntas :---------------------------------------
i. Lainnya, sebutkan :……………………………………………
-
18. Pemeriksaan dalam pertama:
- Jam : .............................................oleh:.......................................
- Hasil:
o Pembukaan:
o Ketuban :
o Serviks
o Molase
19. Laboratorium

20. CTG: Pukul: .....................................kesan:

V. DATA PSIKOSOSIAL dan EKONOMI

1. Penghasilan keluarga setiap bulan:

2. Respon klien terhadap kehamilan sekarang:
3. Respon pasangan terhadap kehamilan sekarang
4. Respon sibling terhadap kehamilan sekarang:
5. Cara pasangan mengenalkan calon adik baru:

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 6. Ketertarikan pasangan selama kehamilan:
7. Pantangan selama kehamilan:
8. Kebudayaan yang dianut:

LAPORAN PERSALINAN

I. PENGKAJIAN AWAL
1. Tanggal:.......................................jam:....................................
2. Tanda-tanda vital: TD:...................mmHg, Nadi:.................x/mnt; Suhu:......... o C,
P:.........x/mnt

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 3. Pemeriksaan palpasi
abdomen:...................................................................................................
4. Hasil periksa
dalam:..........................................................................................................................
5. Persiapan
perineum:.........................................................................................................................
6. Klisma : ya /tidak,
jelaskan:...........................................................................................................
7. Pengeluaran
pervaginam:................................................................................................................
8. Perdarahan pervaginam: ya/ tidak
jelaskan............................................................................
9. Kontraksi uterus: (frekuensi, durasi,
kekuatan):..................................................................
10. DJJ:.............x/mnt, teratur: ya/ tidak
11. Status janin: (hidup/tidak; jumlah:......................presentasi:................................)

II. KALA PERSALINAN

 Kala I
1. Mulai persalinan: tanggal:....................pukul:.............................
2. Tanda dan
gejala:..........................................................................................................................................
........................................................................................................................................................
3. Tanda-tanda vital: TD:...............mmHg; Nadi:..................x/mnt; Suhu:.......... oC;
P:..........x/mnt
4. Lama Kala I:
5. Kondisi
psikososial: ..............................................................................................................
........................................................................................................................................................
........................................................................................................................................................
6. Kebutuhan khusus
klien:.....................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
7. Diagnosa
Keperawatan: ......................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
8. Tindakan:...................................................................................................................................
..
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

9. Pengobatan yang
didapat:....................................................................................................

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 ........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
..........................
10. Observasi kemajuan persalinan
Tgl/jam Kontraksi uterus DJJ Keterangan

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 CATATAN PERSALINAN 24. Masase fundus uteri?
1. Tanggal: …………………………………………….…..  Ya
2. Nama bidan: ……………………………………………  Tidak, alasan……………..…………….…………
3. Tempat persalinan:
25. Plasenta lahir lengkap (intact) Ya / Tidak
 Rumah Ibu  Puskesmas
 Polindes  Rumah Sakit Jika tidak lengkap, tindakan yang dilakukan:
 Klinik Swasta  Lainnya:……………… a. ……………………………………………………
4. Alamat tempat persalinan: …..……………………… b. ……………………………………………………
5. Catatan:  rujuk, kala: I / II / III / IV 26. Plasenta tidak lahir >30 menit :
6. Alasan merujuk: ……….…………….……………..…  Tidak
7 Tempat rujukan: ..……….………………………..……  Ya, tindakan …..………………………………………….………
8. Pendamping pada saat merujuk: ……………...……………………………………………….…..
 bidan  teman  suami  dukun  keluarga  tidak ada 27.Laserasi:
9. Masalah dalam kehamilan/persalinan ini:  Ya, dimana …………………………………..………….
 Gawatdarurat  Perdarahan  HDK  Infeksi  PMTCT  Tidak
KALA I 28. Jika laserasi perinium, derajat: 1 / 2 / 3 / 4
Tindakan:
10. Partogram melewati garis waspada: Y / T  Penjahitan, dengan / tanpa anestesi
11. Masalah lain, sebutkan: ……………………………………………………  Tidak dijahit, alasan…………………………………..
………………………………………………………………………………...
1 12.Penatalaksanaan masalah tsb: ..………… ………………………………. 29. Atoni uteri:
…………………………………………………………………………………  Ya, tindakan: ……………………………………………….
13. Hasilnya: ………………..……………………………. ……………………..  Tidak
30. Jumlah darah yg keluar/perdarahan: ……………………… ml
KALA II 31. Masalah dan penatalaksanaan masalah tersebut: ………..
14. Episiotomi: ……………………………………………………………….…..
 Ya, indikasi …………………………………………… Hasilnya: .………………………..…………………….……
 Tidak
KALA IV
15. Pendamping pada saat persalinan:
32. Kondisi ibu : KU: ….. TD: ….mmHg Nadi: x/mnt Napas: …x/mnt
 suami  teman  tidak ada
33. Masalah dan penatalaksanaan masalah ………………………..
 keluarga  dukun BAYI BARU LAHIR:
16. Gawat janin:
 Ya, tindakan yang dilakukan: 34. Berat badan ………. gram
a ……………………………………………… 35. Panjang badan ……. cm
b ……………………………………………… 36. Jenis kelamin: L / P
 Tidak 37. Penilaian bayi baru lahir : baik / ada penyulit
 Pemantauan DJJ setiap 5-10 menit selama kala II, hasil: ............. 38. Bayi lahir:
17. Distosia bahu  Normal, tindakan:
 Ya, tindakan yang dilakukan: ..………………………………………  mengeringkan
……………………………………………………………………..……  menghangatkan
 Tidak  rangsang taktil
18. Masalah lain, penatalaksanaan masalah tsb dan hasilnya  pakaian/selimuti bayi dan tempatkan di sisi ibu
.…………………………..……………………….................................…  Asfiksia ringan/pucat/biru/lemas, tindakan:
KALA III
 mengeringkan  bebaskan jalan napas
19. Inisiasi Menyusu Dini  rangsang taktil  menghangatkan
 Ya  bebaskan jalan napas  lain-lain, sebutkan:.........................
 Tidak, alasannya .............................................................................  pakaian/selimuti bayi dan tempatkan di sisi ibu
20. Lama kala III: ……….…….……………..… menit  Cacat bawaan, sebutkan:………………….………….
21. Pemberian Oksitosin 10 U im?  Hipotermi, tindakan:
 Ya, waktu: …………menit sesudah persalinan a. ………………………………………………….
 Tidak, alasan………………..…………………..........................…. b. ………………………………………………….
Penjepitan tali pusat ............ menit setelah bayi lahir c. ………………………………………………….
22. Pemberian ulang Oksitosin (2x)?  39. Pemberian ASI
 Ya, alasan……………..…..….……………….….  Ya, waktu:……… jam setelah bayi lahir
 Tidak
 Tidak, alasan…….…………….……….….…….…….
23. Penegangan tali pusat terkendali?
40. Masalah lain, sebutkan:…………………….…….….…..
 Ya Hasilnya: ……………………………………………………
 Tidak, alasan……………..…………….…………

PEMANTAUAN PERSALINAN KALA IV

1. Tinggi 2. Kontr Kandung Kemih

Fundus Uteri aksi Uterus
Jam Ke Waktu Tekanan darah Nadi Darah yg keluar

Gambar 6-3: Halaman Belakang Partograf

 Kala II

1. Kala II dimulai :
Hari/Tanggal :.......................................Jam:..............................
2. Tanda-tanda vital:
TD: .......................mmHg, Nadi: ....................x/mnt, Suhu:.................oC,
P:................x/mnt
3. Lama Kala II: .............jam................menit
4. Tanda dan gejala............................................................................................................................
...............................................................................................................................................................
5. Jelaskan upaya meneran:...........................................................................................................
...............................................................................................................................................................
6. Keadaan psikososial:....................................................................................................................
...............................................................................................................................................................
7. Kebutuhan khusus: ......................................................................................................................
...............................................................................................................................................................
8. Diagnosa Keperawatan:
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
....................
9. Tindakan: .........................................................................................................................................
.......
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
................................................

 Catatan Kelahiran
1. Bayi lahir
jam: .................................................................................................................................
2. Bugar: Ya/ Tidak
3. APGAR Score menit I..................menit ke V: ..........................
4. Perineum (utuh/episiotomi/ruptur), jika ruptur
tingka...........................................
5. Bonding ibu dan
bayi..................................................................................................................
6. Tanda-tanda vital: Nadi:..............x/mnt, RR:............x/mnt, suhu: ..............oC
7. Diagnosa
Keperawatan:........................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...................
8. Tindakan: ..................................................................................................................................
.......

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 ........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...........................
9. Pengobatan: .............................................................................................................................
.......
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...................

 Kala III:
1. Tanda dan gejala: .....................................................................................................................
...........................................................................................................................................................
.........................................................................................................................................................
2. Plasenta lahir jam :...................................................................................................................
3. Cara lahir plasenta: ................................................................................................................
4. Karakteristik Placenta: Ukuran ............cm x .............cm x ................cm
Panjang tali pusat : .........cm
Jumlah pembuluh darah .....................arteri, ..............vena
Selaput ketuban: ......................................................................................................................
Kelainan:......................................................................................................................................
5. Perdarahan : ........ml, karakteristik :.................................................................................
6. Keadaan psikososial : .............................................................................................................
..........................................................................................................................................................
7. Kebutuhan khusus:..................................................................................................................
..........................................................................................................................................................
8. Diagnosa Keperawatan : ......................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
9. Tindakan: ....................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
10. Pengobatan: ............................................................................................................................
...............................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

 Kala IV
1. Mulai jam .....................................................................................................................................
2. Tanda-tanda vital
TD: .......................mmHg, Nadi: ....................x/mnt, Suhu:.................oC,
P:................x/mnt
3. Kontraksi uterus:.....................................................................................................................
4. Perdarahan : ........ml, karakteristik :.................................................................................
5. Keadaan psikososial : ............................................................................................................
..........................................................................................................................................................
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 7.Bonding Ibu dan Bayi : ...........................................................................................................
8. Kebutuhan khusus:..................................................................................................................
..........................................................................................................................................................
9. Diagnosa Keperawatan : ......................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
10. Tindakan:...................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
...........................
11. Pengobatan: .........................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..................

 Bayi
1. Bayi lahir tanggal/ jam : .......................
2. Jenis Kelamin: ...........................................
3. Niali Apgar : I .............................V: .............................
4. PB/ BB/Lingkar kepala: ............cm/ .............. gram/..............cm
5. Karakteristik khusus bayi :..................................................................................................
6. Caput: Suksedanum / cephallhematum
7. Suhu : ...........oC
8. Anus : berlubang / tertutup
9. Perawatan tali pusat : ............................................................................................................
10. Perawatan Mata: ...................................................................................................................
11. Imunisasi Hepatitis I: ya/ tidak, di .,..............................................................................
Pemberian Vitamin K : ya/ tidak, di ...............................................................................
12. Kebutuhan khusus:................................................................................................................
..........................................................................................................................................................
13. Diagnosa Keperawatan : ...................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
14. Tindakan:..................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
..........................................................................................................................................
15. Pengobatan: ............................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

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