ASUHAN KEPERAWATAN MATERNITAS

“ INTRANATAL “

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I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : .......................................................................................
Umur : .......................................................................................
Pendidikan : ...........................................................................
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Pekerjaan : .......................................................................................
Status Perkawinan : .......................................................................................
Agama : .......................................................................................
Suku : .......................................................................................
Alamat : .......................................................................................
No CM : .......................................................................................
Tanggal MRS : .......................................................................................
Tanggal Pengkajian : .......................................................................................
Sumber informasi : .......................................................................................

B. PENANGGUNG JAWAB
Nama : .......................................................................................
Umur : .......................................................................................
Pendidikan
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Jenis kelamin : .......................................................................................
Pekerjaan : .......................................................................................
Alamat : .......................................................................................
Status perkawinan : .......................................................................................
Agama : .......................................................................................

C. DATA KESEHATAN
1. Keluhan Utama
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2. Keluhan Saat Dikaji
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3. Riwayat Keluhan
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D. RIWAYAT OBSTETRI DAN GINEKOLOGI

1. Riwayat Menstruasi
Menarche :....................................................................................................
Banyaknya : ...................................................................................................
 Keluhan : ...................................................................................................
HPHT : ...................................................................................................
Siklus : ...................................................................................................
Lama : ...................................................................................................
2. Riwayat Pernikahan
Menikah : ...................................................................................................
Lama : ...................................................................................................
3. Riwayat Kehamilan, Persalinan, Nifas yang Lalu :
Anak Kehamilan Persalinan Komplikasi nifas Anak
Ke
No Thn Umur Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB PB
Kehamilan Kelamin

Keterangan : ..............................................................................................................
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4. Riwayat Kehamilan Saat Ini
Status Obstetrikus : .............................................................................................
G…P…A…H…
UK : ……..minggu
TP :…..........
ANC kehamilan sekarang :
Trimester I :....................................................................................................
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Trimester II :....................................................................................................
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Timester III :....................................................................................................
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 5. Riwayat keluarga berencana
AKSEPTOR KB
No. Jenis Lama Masalah/Keluhan

Keterangan : ....................................................................................................
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E. RIWAYAT PENYAKIT
1. Klien :................................................................................................................
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2. Keluarga:..............................................................................................................
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F. POLA FUNGSIONAL KESEHATAN
1. Pemeliharan dan persepsi terhadap kesehatan
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2. Nutrisi / metabolik
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3. Pola eliminasi
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4. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0 : mandiri, 1 : alat Bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan
alat, 4 : tergantung total
5. Oksigenasi
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6. Pola tidur dan istirahat
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7. Pola perseptual
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8. Pola persepsi diri

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9. Pola seksual dan reproduksi
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10. Pola peran – hubungan
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11. Pola manajemen koping stress
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12. Sistem nilai dan keyakinan
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G. PEMERIKSAAN FISIK
Keadaan umum :
GCS :…………………..
Tingkat kesadaran : ………………….
Tanda – tanda vital : TD:….. ........... N:…......... RR:…......... T:….......
BB (sekarang) : …………. TB:………… LILA :………..
BB (sebelum hamil) :.......................
Head toe toe :
Kepala :...........................................................................
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Wajah :...........................................................................
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Sklera :...........................................................................
Konjungtiva : :...........................................................................
Pembesaran limphe node :...........................................................................
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Pembesaran kelenjar tiroid :...........................................................................
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Telinga :...........................................................................
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Kulit :
Linea nigra ( )
Striae gravidarum ( )
Pucat ( )
Cloasma ( )
Dada :
Payudara :.......................................
Areola :....................................... Putting : (menonjol / tidak )
Tanda dimpling / retraksi :………………….
Pengeluaran ASI : ………………..
Jantung :
I:
P:
P:
A:
Paru:
I:
P:
P:
A:

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 :
Keputihan :…………………. Karakteristik :……………..
Hemoroid :…………………

Ekstremitas :
Atas :
Oedema :…………………
Varises :…………………
CRT :…………………
 Refleks :………………....
Bawah :
Oedema :…………………
Varises :…………………
CRT :…………………
Refleks :………………....

H. DATA PENUNJANG
Pemeriksaan Laboratorium :………………………..

I. DIAGNOSA MEDIS
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J. PENGOBATAN
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II. OBSERVASI PERSALINAN
A. KALA I
1. DATA FOKUS KALA I
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B. KALA II
1. DATA FOKUS KALA II
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C. KALA III
1. DATA FOKUS KALA III
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D. KALA IV
1. DATA FOKUS KALA IV
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