PENGKAJIAN INTRANATALNama Mahasiswa:
..............................................Tanggal Pengkajian:
..............................................NIM:
..............................................RS/Ruangan:
...............................................A. DATA UMUMInisial
klien: ................(.....thn) Nama Suami:
....................(......thn)Pekerjaan :
.......................... Pekerjaan:
..................................Pendidikan:
.......................... Pendidikan :
..............................Agama: ..........................
Agama: ..................................Suku bangsa:
..........................Status perkawinan :
........................Alamat:
.............................................................................................B.
DATA UMUM KESEHATAN1. TB/BB:
................cm/.................kg2. BB sebelum hamil:
.....................kg3. Masalah kesehatan khusus :
........................................................................4.
Obat-obatan :
..............................................................................................5.
Alergi (obat/makanan/bahan tertentu) :
......................................................6. Diet
khusus :
..............................................................................................7.
Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat
dengar/tidak ada)*8. Frekuensi BAB/BAK
:.................................................................................9.
Masalah BAB/BAK :
.................................................................................10.
Kebiasaan waktu tidur :
.......................................................................................................................................................................................................................................................................................................
C. DATA UMUM KEBIDANAN1. Kehamilan sekarang direncanakan
(ya/tidak)*2. Status Obstetri: G ...........P.............A
............H ..............(minggu)3.
HPHT:............................Taksiran partus :
.........................4. Jumlah anak di rumahNoJenis kelaminCara
lahirBB LahirKeadaan saat iniUmur
1
2
3
4
5
5. Mengikuti kelas prenatal (ya/tidak)6. Jumlah kunjungan ANC
pada kehamilan ini : .......................................7.
Masalah kehamilan yang lalu:
......................................................................................................................................................................................................................................................................................8.
Masalah kehamilan sekarang:
.......................................................................................................................................................................................................................................................................................9.
Rencana KB: ..................................................10.
Makanan bayi sebelumnya :
ASI/PASI/lainnya.....................................11. Pelajaran
yang diinginkan saat ini : (lingkari)Relaksasi,/pernafasan/manfaat
ASI/cara memberi minum botol/senam nifas/metode KB/perawatan
perineum/perawatan payudara/lain-lain,jelaskan
....................................................................................12.
Setelah bayi lahir, siapa yang diharapkan
membantu.......................................................................................................13.
Masalah dalam persalinan yang
lalu.............................................................................................................................................................................................................................
D. RIWAYAT PERSALINAN SEKARANG1. Mulai persalinan (kontraksi):
tanggal/jam : ............................2. Pengeluaran pervaginam
(tanggal/jam) : ...............................3. Keadaan kontraksi
(frekuensi dalam 10 menit, lamanya, kekuatannya) :
..................................................................................................................................................................................................................................................................................................................................................................4.
Denyut Jantung
JaninFrekuensi:.......................................Kualitas :
.......................................Irama :
.......................................5. Pemeriksaan fisik a.
Kenaikan BB selama hamil : .....................kgb. TTV :
TD......................mmHg,N.......................x/mnt
S...............oC P..............x/mntc. Kepala dan
leher:................................................(normal/tidak)d.
Jantung:
..................................................................................e.
Paru-paru :
......................................................................f.
Payudara :
......................................................................g.
Abdomen : (secara umum dan pemeriksaan
obstetrik).............................................................................................................................................................................................................................h.
Ekstremitas : edema/tidaki. Refleks :
..........................................................................................j.
Pemeriksaan dalam pertama :(jam) .................oleh :
..................Hasil:...................................................................................Ketuban:
(utuh/pecah), jika sudah pecah : tgl/jam :.......................
warna...................................k. Laboratorium
:.................................................................................................................................................................................................................................................................................................................E.
DATA PSIKOSOSIAL1. Penghasilan keluarga setiap
bulan.......................................................................................................2.
Perasaan klien terhadap kehamilan
sekarang.......................................................................................................3.
Perasaan suami terhadap kehamilan
sekarang.......................................................................................................4.
Jelaskan respon sibling terhadap kehamilan
sekarang......................................................................................................
LAPORAN PERSALINANA. Pengkajian awal1. Tanggal :
.........................Jam : ............................2. TTV :
TD......................mmHg,N.......................x/mnt
S...............oC P..............x/mnt3. Pemeriksaan palpasi
abdomenLeopold I:
..................................................................................Leopold
II : .
................................................................................Leopold
III :
..................................................................................Leopold
IV :
.................................................................................4.
Hasil pemeriksaan
dalam..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................5.
Pemeriksaan perineum
.............................................................................................................................................................................................................................6.
Dilakukan klisma (ya/tidak) :
.............................................................7.
Pengeluaran pervaginam :
................................................................8.
Perdarahan pervaginam (ya/tidak)
:.....................................................9. Kontraksi
uterus (frekuensi, lamanya, kekuatan)
.............................................................................................................................................................................................................................10.
DJJ
:(frekuensi/kualitas)................................./..........................................11.
Status janin : (hidup/tidak,jumlah,presentasi)
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................B.
Kala persalinanKala I1. Mulai Kontraksi, Pecah ketuban :
(tanggal/jam)........................................2. Tanda dan
gejala :
.........................................................................................................................................................................................................................................................................................................3.
Lama Kala I :
(jam/menit/detik).................................................................4.
Keadaan psikososial :
..............................................................................5.
Kebutuhan khusus klien :
............................................................................6.
Tindakan
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................7.
Pengobatan.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................8.
Observasi kemajuan persalinan :Tanggal/jamKontraksi
uterusDJJKeterangan
Kala II1. Kala II dimulai : (Tgl/jam) :
.......................................................................2.
TTV : TD......................mmHg,N.......................x/mnt
S...............oC P..............x/mnt3. Lama kala II :
(..jam/.menit/detik)4. Tanda dan
gejala...................................................................................................................................................................................................................................................................................................................................................5.
Upaya meneran, Jelaskan
........................................................................................................................................................................................6.
Keadaan psikososial :
....................................................................................................................................................................................7.
Kebutuhan khusus klien :
..............................................................................................................................................................................8.
Tindakan..........................................................................................
....................................................................................................................................................................................................................................................................................................................................................Catatan
Kelahiran1. Bayi lahir jam:
.......................................................................2.
APGAR menit I..................................... menit
V..............................3. Perineum
(utuh/episiotomi/ruptur)*, jika ruptur, tingkat ruptur :
...............4. TTV bayi :
TD......................mmHg,N...............x/mnt
S...............oC P..............x/mnt5. Pengobatan :
.......................................................................................................................................................................................................................................................................................................................................................................................................................................Kala
III1. Mulai jam : .................2. TTV :
TD......................mmHg,N.......................x/mnt
S...............oC P..............x/mnt3. Tanda dan gejala
:.................................................................................................................................................................................................................................................................................................................................................................................................................................4.
Plasenta lahir jam :
................................................................................5.
Cara lahir plasenta
:.........................................................................6.
Karakteristik plasenta
.....................................................................Diameter
: ..............cmKetebalan : .............cmPanjang tali pusat :
...............cmJumlah pembuluh darah
:.........................arteri
.......................venaInsersio tali pusat :
..........................................................................Kelainan
:
........................................................................................Perdarahan
: .........................ml7. Karakteristik perdarahan :
...............................................................8.
Keadaan psikososial :
......................................................................9.
Kebutuhan khusus :
.........................................................................10.
Tindakan :
.........................................................................................................................................................................................................................................................................................................................................................................................................................................11.
Pengobatan :
......................................................................................................................................................................................................................................................................................................................................................................................................................................
Kala IV1. Mulai jam : ................2. TTV :
TD......................mmHg,N.......................x/mnt
S...............oC P..............x/mnt3. Kontraksi uterus :
.......................................................................................4.
Perdarahan :......................mlKarakteristik :
.............................................................................................5.
Bonding ibu dan
bayi:........................................................................................................................................................................................6.
Tindakan :
......................................................................................................................................................................................................................................................................................................................Bayi
1. Bayi lahir jam:
................................................................................2.
Jenis kelamin :
.................................................................................3.
Nilai APGAR:
.......................................................................4.
BB/PB/lingkar kepala :
...................gram.....................cm....................cm5.
Karakteristik khusus bayi :
.........................................................................6.
Kaput suksadaneum/cephal hematoma :
....................................................7. Anus :
berlubang/tertutup*8. Perawatan tali pusat
:.........................................................................9.
Perawatan mata :
..............................................................................
