PROGRAM STUDI S1 KEPERAWATAN

FAKULTAS ILMU KESEHATAN

UNIVERSITAS MERDEKA SURABAYA

PENGKAJIAN INTRANATAL
Rumah sakit

: ................................................

Ruangan

: ................................................

Tgl/Jam MRS

: ...............................................

Dx. Medis

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No. Register

: ...............................................

Yang Merujuk

: ...............................................

Pengkajian oleh

: ...............................................

Tgl/Jam Pengkajian

: ...............................................

I. BIODATA
Nama Klien

: ......................................

Nama Suami

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Umur

: ......................................

Umur

: ......................................

Suku/Bangsa

: ......................................

Suku/Bangsa

: ......................................

Pendidikan

: .......................................

Pendidikan

: ......................................

Pekerjaan

: ......................................

Pekerjaan

: ......................................

Agama

: ......................................

Agama

: .......................................

Penghasilan

: ......................................

Penghasilan

: ......................................

Gol. Darah

: ......................................

Gol. Darah

: ......................................

Alamat

: ......................................

Alamat

: ......................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama
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2. Riwayat Penyakit Sekarang

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3. Riwayat Penyakit Dahulu

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4. Riwayat Kesehatan Keluarga

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5. Riwayat Psikososial
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6. Pola Pola Fungsi Kesehatan
a. Pola persepsi & tata laksana hidup sehat
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b. Pola nutrisi & metabolisme
1) Makan:
Keterangan
Frekuensi
Jenis

Sebelum sakit

Saat sakit

Porsi
Total konsumsi
Kebutuhan
Balance nutrisi
Keluhan
2) Minum:
Keterangan

Sebelum sakit

Saat sakit

Frekuensi
Jenis
Total konsumsi
keluhan

c. Pola aktivitas
Keterangan

Sebelum sakit

Saat sakit

Mobilitas rutin
Waktu senggang
Mandi
Berpakaian
Berhias
Toileting
Makan minum
Tingkat ketergantungan

d. Pola eliminasi
1) Eliminasi uri:
Keterangan
Frekuensi
Pancaran
Jumlah
Bau
Warna

Sebelum sakit

Saat sakit

Perasaan setelah BAK

Total produksi urine

2) Eliminasi alvi:
Keterangan

Sebelum sakit

Saat sakit

Frekuensi
Konsistensi
Bau
Warna
Keluhan

e. Pola persepsi sensoris

- Penglihatan:..............................................................................................................
- Pendengaran:............................................................................................................
- Pengecap:..................................................................................................................
- Pembau:....................................................................................................................
- Peraba:......................................................................................................................

f. Pola konsep diri

- Gambaran diri: .........................................................................................................
- Ideal diri: ..................................................................................................................
- Identitas diri: ............................................................................................................
- Peran diri: .................................................................................................................
- Harga diri: ................................................................................................................

g. Pola hubungan & peran

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h. Pola reproduksi & seksual
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i. Pola penanggulangan stres / Koping Toleransi Stres

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7. Riwayat Pengkajian Obstetri, Prenatal dan Intranatal

a. Riwayat penggunaan kontrasepsi
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b. Riwayat menstruasi
Menarche

: ..........................................................

Lamanya

: ..........................................................

Siklus

: ..........................................................

Hari pertama haid terakhir

: ..........................................................

Dismenorhoe

: ..........................................................

Fluor albus

: ..........................................................

c. Riwayat kehamilan dahulu

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d. Riwayat kehamilan sekarang

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e. Riwayat persalinan dahulu

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8. Pemeriksaan Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi,)

a. Keadaan Umum
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b. Tanda Tanda Vital
Tekanan darah

: ..........................

Respirasi

: .............................

Denyut Nadi

: ..........................

TB / BB

: ............................

Suhu Tubuh

: ..........................

c. Kepala & Leher

Rambut : ....................................................................................................................
Muka

: ....................................................................................................................

Mata

: ....................................................................................................................

Hidung : ....................................................................................................................
Telinga : ....................................................................................................................
Mulut

: ....................................................................................................................

Leher

: ....................................................................................................................

d. Thorax / Dada
1) Cardio:
- Inspeksi

: .....................................................................................................

- Palpasi

: .....................................................................................................

- Perkusi

: .....................................................................................................

- Auskultasi

: .....................................................................................................

2) Pulmonal
- Inspeksi

: ......................................................................................................

- Palpasi

: ......................................................................................................

- Perkusi

: ......................................................................................................

- Auskultasi

: ......................................................................................................

e. Pemeriksaan Payudara
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f. Abdomen
- Inspeksi

: ........................................................................................................

- Auskultasi

: ........................................................................................................

- Perkusi

: ........................................................................................................

- Pemeriksaan Leopold
Leopold I

: ........................................................................................................

Leopold II

: ........................................................................................................

Leopold III

: ........................................................................................................

Leopold IV

: ........................................................................................................

- His

: ........................................................................................................

- DJJ

: .........................................................................................................

- Kesimpulan

: ........................................................................................................

g. Genetalia dan anus

- Vulva

: .........................................................................................

- Perinemun

: .........................................................................................

- Keluaran pervaginam

: .........................................................................................

- Vagina toucher

: .........................................................................................

Hasil: ........................................................................................................................
- Ketuban pecah jam ..................................................................................................
- Anus

: .........................................................................................

- Kesimpulan

: .........................................................................................

h. Punggung
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i. Ekstremitas
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j. Integumen
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k. Pemeriksaan Laboratorium
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Urine :
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Darah :
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Feces :
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l. Pemeriksaan Diagnostik Lain

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LAPORAN PERSALINAN

I.

Kala I/Pembukaan ostium uteri (pemeriksaan toucher dan sebagainya)

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II. Kala II / Pengeluaran Bayi

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III. Kala III / Pengeluaran Uri

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IV. Kala IV / mulai pengeluaran uri sampai 2 jam post partum (kontraksi uteri, TFU,
pengeluaran darah pervaginam, observasi tanda tanda vital / keadaan umum ibu).
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CATATAN LUAR BIASA :

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PLASENTA DAN BAYI BARU LAHIR

A. PLASENTA
Lengkap

: ..................................................

Berat

: ..................................................

Panjang tali pusat

: ..................................................

Kotiledon

: ..................................................

Insertio

: ..................................................

Keadaan luar biasa : ..................................................

B. Pengkajian Khusus Bayi

- Tanggal Lahir

: ..................................................

- Apgar Score

: ..................................................

- Asphyxia

: ..................................................

- Pemeriksaan fisik

1. Kepala

: ........................................................................................................

2. Muka

: ........................................................................................................

3. Telinga

: ........................................................................................................

4. Mulut

: ........................................................................................................

5. Dada

: ........................................................................................................

6. Abdomen

: .........................................................................................................

7. Tulang belakang : ........................................................................................................

8. Geneto urenal

: ........................................................................................................

9. Anus

: ........................................................................................................

10. Ekstremitas

: ........................................................................................................

11. Refleks

: ........................................................................................................

12. Kulit

: ........................................................................................................

- Pengukuran
1. B.B

: ............................................

2. P.B

: ............................................

3. Lingkar kepala

: ............................................

4. Lingkar dada

: ..............................................

..................., .................................
Mahasiswa

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