PROGRAM STUDI PENDIDIKAN PROFESI NERS

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER

FORMAT PENGKAJIAN INTRANATAL

Rumah Sakit : ……………………………………………………………

Ruangan : ……………………………………………………………
Tgl/Jam MRS : ……………………………………………………………
Dx. Medis : ……………………………………………………………
No. Register : ……………………………………………………………
Yang Merujuk : ……………………………………………………………

Pengkajian oleh : …………………………………………………………..

Tgl/Jam Pengkajian : …………………………………………………………..

I. BIODATA

Nama Klien : ........................... Nama Suami : .............................

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 (permulaan his, keadaan ketuban, pengeluaran pervaginam)

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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
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c. Pola aktivitas
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d. Pola eliminasi
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e. Pola persepsi sensoris
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f. Pola konsep diri
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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 mentruasi
Menarche : ……………………………………………………
Lamanya : ……………………………………………………
Siklus : ……………………………………………………
Hari pertama haid terakhir : …………………………………………..
Dismenorhoe : ……………………………………………………
Fluor albus : …………………………………………………………..

c. Riwayat kehamilan terdahulu

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d. Riwayat kehamilan sekarang
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e. Riwayat persalinan lalu
Jumlah anak :
Jenis kelamin :
Tempat persainan :
Penolong persalinan :
Tanggal persalinan :
Kehamilan direncanakan+tidak :
Komplikasi selama kehamilan :
Komplikasi selama nifas :
Jenis persalinan :
Spontan pervaginam :
Forceps :
Vakum :
Oksitosin drip :
 Section caesaria :
Pengobatan selama kehamilan :
Persalinan nifas :
Alasan pengobatan :
Riwayat ANC :
Tempat :
Pemeriksa :
Keteraturan :
Imunisasi :

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

a. Keadaan Umum
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b. Tanda-tanda vital
Suhu Tubuh : Respirasi :
Denyut Nadi : TB / BB :
Tensi / Nadi :

c. Kepala & leher

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d. Thorax / Dada
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e. Pemeriksaan payudara
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f. Abdomen
1) Inspeksi
Adanya striae gravidarum :
Linea alba/linea nigra :
Jaringan parut/ bekas operasi :
Bentuk perut :
2) Palpasi

- Pemeriksaan Leopold
- Leopold I
- Leopold II
- Leopold III
- Leopold IV
- Panjang TFU – simfisis TBJ
 - Merasakan gerakan janin
- His ………………………………………………………………..
- DJJ ………………………………………………………………..
- Kesimpulan ……………………………………………………….
3) Auskultasi
DJJ:
Punctum maksimum
Tempat:
Frekuensi
Tertur atau tidak
Kesimpulan
Eristalti usus

g. Genetalia dan anus

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- Keluaran pervaginam : ……………………………………………

- Vulva, odem, lesi :
- Adakah doranteknusperjolvulka:
- Vagina Toucher : ( jam ………………… oleh : ………………… hasil
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- Ketuban …………………………………………………………..
- Anus dan perineum:
- Score bisep: ………………………………………………………………
- Kesimpulan ……………………………………………………….

h. Punggung
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i. Ekstremitas
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j. Integumen
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f. Pemeriksaan laboratorium
- Urine :
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- Darah
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- Feces :
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 g. Pemeriksaan Diagnostik Lain
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2 LAPORAN PERSALINAN

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

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Tgl./Jam :
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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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Keterangan : sertakan lembar Partograf.

 KETERANGAN PLASENTA DAN BAYI BARU LAHIR

A. PLASENTA

Lengkap : …………… .............................

Berat : ..................................................
Panjang tali pusat : ..................................................
Kotiledon : ..................................................
Insertio : ……………………..................
Keadaan luar biasa:
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B. Pengkajian Khusus Bayi

- Tanggal lahir : .............................................................................................

- Apgar Score : ……………………………………………………………

- Asphyxia : …………………………………………………………….

- Pemeriksaan fisik :
1. Ke p a l a : ……………………………………………………………
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2. M u k a : ……………………………………………………………..
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3. Telinga : ……………………………………………………………..
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4. M u l u t : ……………………………………………………………..
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5. D a d a : ……………………………………………………………….
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6. Abdomen : ……………………………………………………………
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7. Tulang belakang : …………………………………………………….
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8. Geneto urenal : ………………………………………………………..
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9. A n u s : ………………………………………………………………
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10.Ekstremitas : .........................................................................................
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11.Refleks : ................................................................................................
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12.K u l i t : ................................................................................................
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- Pengukuran
1. B . B.……………………………………………………………………
2. P . B……………………………………………………………………
3. Lingkar Kepala ………………………………………………………..
4. Lingkar Dada …………………………………………………………

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Mahasiswa

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