Pengkajian Intranatal

PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA PERIODE INTRANATAL

Nama Mahasiswa: .. Tempat Praktek: Nomor Mahasiswa: .. Tanggal Praktek: Tanggal pengkajian: ..

DATA UMUMInisial Klien: . Nama Suami: ..Umur: . Alamat: ..Pekerjaan: . Pekerjaan: ..Pendidikan Terakhir: . Agama: ..Suku bangsa: . Pendidikan terakhir: ..Status perkawinan: .

DATA UMUM KESEHATAN1. Tinggi/Berat Badan cm/ kg2. Berat Badan sebelum hamil kg3. Masalah kesehatan khusus .....4. Obat obatan 5. Alergi (makanan/obat-obatan/bahan tertentu) ...6. Diet khusus 7. Menggunakan alat bantu: gigi tiruan/kacamata/kontak lensa/alat dengar, lain-lain. Sebutkan....8. Frekuensi BAB kali/hariMasalah ..9. Frekuensi BAK kali/hariMasalah ..10. Kebiasaan waktu tidur ...........

DATA UMUM MATERNITAS1. Kehamilan sekarang direncanakan (ya/tidak) : ......2. Status Obstetrikus : G..P..A.. Usia kehamilan...3. HPHT Tafsiran partus ...4. Jumlah anak dirumah .....

NOJenis KelaminCara lahirTempat persalinan dan penolongBB lahirKomplikasi selama proses persalinanKeadaan saat iniUmur

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5. Mengikuti kelas prenatal (ya/tidak) ...6. Jumlah kunjungan selama kehamilan ini ...7. Masalah kehamilan yang lain a. Trimester I: ..b. Trimester II: ..c. Trimester III: ..8. Masalah kehamilan sekarang .9. Kontrasepsi yang pernah dipakai ...Masalah yang pernah dialami selama penggunaan alat konterasepsi ini ...Rencana KB setelah kehamilan ini ....................10. Makanan bayi sebelumnya ASI/PASI ...11. Pendidikan kesehatan yang ingin ibu dapatkan selama perawatan (Beri tanda didepan option) Relaksasi pernafasan Manfaat ASI dan cara menyusui yang baik Senam nifas Metode KB Perawatan perineum Perawatan payudara12. Setelah bayi lahir siapa yang diharapkan membantu: suami/teman/orang tua atau yang lain 13. Masalah persalinan yang lalu .........................................................................................................................................................................................................................................................................................................

RIWAYAT PERSALINAN SEKARANG1. Mulai persalinan (kontraksi/pengeluaran pervaginam ) : tgl /jam..............2. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatan) .3. Frekuensi dan kekuatan denyut jantung janin .. x/menit4. Pemeriksaan fisik:Kenaikan Berat Badan selama kehamilan kgTanda vital : TD= mmHg Suhu= CNadi= x/menit Respirasi= x/mnta. Kepala/leher ..b. Dada (jantung, paru-paru) .c. Payudara d. Abdomen (secara umum dan pemeriksaan) ..e. Kontraksi DJJ f. Ekstremitas (edema/tidak) .g. Refleks ..

5. Pemeriksaan dalamJam PemeriksaanOlehHasil

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6. Ketuban (utuh/pecah) Jika sudah pecah tgl/jam . Warna ...7. LaboratoriumTanggal dan jenis pemeriksaanHasil pemeriksaan normalInterpretasi

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8. Terapi yang diberikanTanggalJenis terapiRute terapiDosisIndikasi terapi

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DATA PSIKOSOSIAL1. Penghasilan keluarga setiap bulan: Rp ..2. Bagaimana perasaan anda terhadap kehamilan sekarang ..............3. Bagaimana perasaan pasangan anda terhadap kehamilan sekarang ......................................................................................................................................................................................................................................................................................................................4. Jelaskan respon sibling terhadap kehamilan sekarang ..............

LAPORAN PERSALINAN

Kala 1TanggalJamHasil Observasi

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Asuhan Keperawatan Kala 1TanggalDiagnosa keperawatanTujuanIntervensiImplementasiEvaluasi

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Keadaan Umum bayi baru lahirBerat badan: ...Panjang badan: ...Lingkar kepala: ...Lingkar dada: ...Lingkar perut: ...Lingkar lengan atas: ...

APGAR SKORNoTgl/JamKarakteristik yang dinilai012

Denyut jantung

Pernafasan

Refleks

Tonus otot

Warna kulit

Total Menit 1 : Menit 5 : Kesimpulan : ...Kala 3TanggalJamHasil Observasi

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Asuhan Keperawatan Pasca OperasiTanggalDiagnosa keperawatanTujuanIntervensiImplementasiEvaluasi

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Pengkajian Intranatal

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