LAPORAN PENDAHULUAN

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Oleh :

Putu Pande Dirgantara, S.Kep

NIM. 17089142050

SEKOLAH TINGGI ILMU KESEHATAN BULELENG

PROGRAM STUDI PROFESI NERS
2017
 Lembar Pengesahan

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Telah disahkan dan diterima oleh Clinical Instruktur (CI) dan Clinical
Teacher (CT) Stase Keperawatan Maternitas sebagai syarat memperoleh nilai dari
Departement Keperawatan Maternitas Program Profesi Ners STIKes Buleleng.

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Clinical Instructure (CI) Clinical Teacher (CT)
Ruang ............................................. Stase Keperawatan Maternitas
RSUD ............................................. STIKes BULELENG,

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NIP. NIK.
 FORMAT ASUHAN KEPERAWATAN MATERNITAS
”INTANATAL”

A. PENGKAJIAN
I. Identitas Pasien
Nama : .............................................................
Umur : .............................................................
Pendidikan : .............................................................
Pekerjaan : .............................................................
Status Perkawinan : .............................................................
Agama : .............................................................
Suku Bangsa : .............................................................
Alamat : .............................................................
Identitas Suami
Nama : .............................................................
Umur : .............................................................
Pendidikan : .............................................................
Pekerjaan : .............................................................
Alamat : .............................................................

II. Data Umum

1. TB ........ cm, BB ......... kg
2. BB sebelum hamil ......... kg
3. Masalah kesehatan khusus
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4. Obat-obatan
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 5. Alergi (obat/makanan/bahan
tertentu) :.................................................................................................
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6. Diet
khusus .....................................................................................................
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7. Alat Bantu yang digunakan :gigi tiruan/kacamata/lensakontak/alat
dengar )*
Lain-lain, sebutkan:.................................................................................
8. Frekuensi BAK
Masalah ..................................................................................................
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9. Frekuensi BAB
Masalah ..................................................................................................
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10. Kebiasaan waktu
tidur ........................................................................................................
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III. Data Umum Kebidanan

a. Riwayat Obstetri dan Ginekologi
1. Riwayat Menstruasi
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2. Riwayat Pernikahan
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b. Riwayat Kehamilan Saaat Ini
1. Kehamilan sekarang direncanakan : ya tidak
2. Status obstetri : G ..... P ….. A ….. H ….., UK : ………. minggu
3. HPHT : ......................................
Taksiran Partus : .....................................
4. Jumlah anak di rumah
No Jenis Kelamin Cara lahir BB lahir Keadaan Umur
1
2
3
4
5
6
5. Mengikuti kelas prenatal : ya/tidak
6. ANC pada kehamilan ini
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7. Masalah kehamilan yang lalu
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8. Masalah kehamilan sekarang
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9. Riwayat/Rencana KB
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10. Makanan bayi sebelumnya : ASI/PASI/lainnya
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11. Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi/pernafasan/manfaat ASI/cara memberi minum
botol/senam nifas/metoda KB/perawatan perineum/perawatan
payudara, lain-lain
Jelaskan...............................................................................................
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12. Setelah bayi lahir, siapa yang diharapkan membantu
(suami/teman/orangtua )*
13. Masalah dalam persalinan yang lalu
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IV. Riwayat Persalinan Sekarang
1. Mulai persalinan (kontraksi/pengeluaran pervaginam)
a. Kontraksi
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b. Pengeluaran Pervagina
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2. Keadaan kontraksi
frekuensi dalam 10 menit ............, lamanya ........ detik,
kekuatan ...........
3. Frekuensi, kualitas, dan keteraturan denyut jantung janin
…………………………...........................................................................
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4. Pemeriksaan fisik:
a. Kenaikan BB selama kehamilan ......... kg
b. Tanda vital: TD ……..... mmHg, Nadi ….... x/menit, Suhu ....... oC,
Pernapasan ....... x/menit
c. Kepala dan Wajah
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d. Leher
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e. Jantung
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f. Paru-paru
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g. Payudara …………………………………..
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h. Abdomen
Inspeksi
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Palpasi
 Leopod I ........................................................................................
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 Leopod II .......................................................................................
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 Leopod III .....................................................................................
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 Leopod IV .....................................................................................
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 Vesika Urinaria .................................................................................
Kontraksi ...........................................................................................
Auskultasi
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i. Ekstremitas
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j. Genetalia
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k. Anus dan Perinium
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l. Pemeriksaan dalam pertama
Jam ………… WITA, dilakukan oleh ……………………………...
Hasil ………..
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m. Ketuban (utuh/pecah), jika sudah pecah
Tgl/Jam ………………………...., warna ……………….…………
n. Laboratorium
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V. Data Psikososial
1. Penghasilan keluarga setiap bulan
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2. Perasaan klien terhadap kehamilan sekarang
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3. Perasaan suami terhadap kehamilan sekarang
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 LAPORAN PERSALINAN

I. Pengkajian Awal
1. Tanggal ..............................., Jam ................ WITA
2. Tanda-tanda vitaI : TD .............. mmHg, Nadi ….... x/menit, Suhu ....... oC,
Pernafasan ......... x/menit
3. Pemeriksaan abdomen (Palpasi)
 Leopod I ……………………………………………………………….
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 Leopod II ……………………………………………………………....
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 Leopod III ……………………………………………………………...
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 Leopod IV ……………………………………………………………..
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4. Hasil periksa dalam
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5. Persiapan perineum
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6. Dilakukan klisma (ya/tidak)
Jelaskan .........................................................................................................
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7. Pengeluaran pervaginam
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8. Perdarahan pervaginam (ya/tidak)
Jelaskan .........................................................................................................
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9. Kontraksi uterus (frekuensi, lamanya, kekuatan)
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10. Denyut jantung janin (frekuensi, kualitas)
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11. Status janin (hidup/tidak, jumlah, presentasi)
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II. Kala Persalinan

 Kala I
1. Mulai persalinan tanggal ............................., jam ………. WITA
2. Tanda dan
gejala ......................................................................................................
...........
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3. Tanda-tanda vitaI: TD ........... mmHg, Nadi ...... x/menit, Suhu .…. °C,
Pernafasan ...... x/menit
4. Lama kala I ........... jam .......... menit ……. detik
 5. Keadaan
psikososial ..............................................................................................
...................
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6. Kebutuhan khusus klien
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7. Tindakan .................................................................................................
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8. Pengobatan .............................................................................................
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9. Observasi kemajuan persalinan
Tanggal/Jam Kontraksi Uterus DJJ Keterangan

 Kala II
1. Kala II dimulai tanggal .................. Jam .............. WITA
2. Tanda-tanda vitaI: TD ........... mmHg, Nadi ...... x/menit, Suhu ...... oC,
Pernafasan ....... x/menit
 3. Lama kala II ….... jam ........ menit …… detik
4. Tanda dan
gejala ......................................................................................................
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5. Jelaskan upaya
mengejan ................................................................................................
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6. Keadaan
psikososial ..............................................................................................
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7. Kebutuhan
khusus .....................................................................................................
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8.
Tindakan .................................................................................................
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 Catatan Kelahiran
 1. Bayi lahir jam .............. WITA, jenis kelamin ...............................
2. Nilai APGAR menit I ..........., menit V ...........
3. Perineum (utuh/episiotomi/ruptur), jika ruptur, tingkat .........................
4. Bonding ibu dan bayi .............................................................................
5. Tanda-tanda vitaI: TD ........... mmHg, Nadi ...... x/menit, Suhu ….. °C,
Pernafasan ......... x/menit
6. Pengobatan
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 Kala III
1. Tanda dan
gejala .......................................................................................................
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2. Plasenta lahir jam ............ WITA
3. Cara lahir
plasenta ...................................................................................................
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4. Karakteristik Plasenta
Ukuran ............................... cm, tebal .......... cm, berat .......... gram
Panjang tali pusat .......... cm
Jumlah pembuluh darah : Arteri …................. Vena .............................
 Kelainan : ...............................................................................................
5. Perdarahan : ……..... cc, karakteristik ...................................................
6. Keadaan
psikososial ..............................................................................................
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7. Kebutuhan khusus
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8. Tindakan
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10. Pengobatan
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 Kala IV
1. Mulai jam .......... WITA
2. Tanda-tanda vitaI : TD …...... mmHg, Nadi ...... x/menit, Suhu ..... OC,
Pernafasn ....... x/rnenit
3. Kontraksi uterus ……………....
……….............................................................................
4. Perdarahan ……..... cc, karakteristik ..............……...............................
5. Bonding ibu dan bayi
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6. Tindakan
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 BAYI
1. Bayi lahir tanggal ………………., jam ……… WITA
2. Jenis kelamin ..................................
3. Nilai APGAR menit I ............. , menit V .............
4. BB ............ gram, PB ......... cm, lingkar kepala bayi …........ cm
5. Karakteristik khusus
bayi .........................................................................................................
........
6. Kaput (suksedaneum/cephalhematom) .......................
7. Suhu ........ OC
8. Anus berlubang/tertutup
9. Perawatan tali pusat
…….........................................................................................................
10. Perawatan mata
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Syair Obstetri
Tanggal/Jam Keterangan
Lembar Partograf bagian belakang Persalinan Kala Satu
CATATAN PERSALINAN
Tanggal : ……../……./……… Penolong Persalinan : ....................................
KALA I :
 Partogram melewati garis waspada
 Ketuban : ............................................................................................................
 Lain-lain, sebutkan : ………................................................................................
 Penatalaksanaan yang dilakukan untuk masalah tersebut : ……........................
Bagaimana hasilnya ? .........................................................................................
KALA II :
Lama Kala II : .......... menit Episiotomi :  tidak  ya, indikasi : ...........................
Pendamping pada saat persalinan : suami keluarga teman dukun tidak ada
Gawat janin :  miringkan ibu ke sisi kiri  minta ibu menarik napas  Episiotomi
Distosia bahu :  Manuver Mc Robert  Ibu merangkak  Lainnya ........................
Lain-lain sebutkan : ………………………………………….................................
Penatalaksanaan yang dilakukan untuk masalah tersebut :.....................................
Bagaimana hasihtya ? .............................................................................................
KALA III :
Lama Kala III : ..................... menit Jumlah pendarahan ......................... ml
a. Pemberian Oksitosin 10 U im < 2 menit?  ya  tidak, alasan ...........................
Pemberian ulang Oksitosin(2x)?  ya, alasan ....................................................
b. Penegangau tali pusat terkendali ?  ya  tidak, alasan .....................................
c. Mesase fiwdus uteri?  ya tidak, alasan ……………………….......................
Laserar Perieum, derajat ....... Tindakan :  penjahitan dengan/tanpa (*) anestesi
Plasenta tidak lahir > 30 menit :  Mengeluarkan secara manual  Merujuk
 Tindakan lain : ...................................................
Atom Uteri :  kompresi bimanual intema  metil ergometrin 0,2 mg im  oksitosin drip
Lain-lain, sebutkan :...............................................................................................
Penatalaksanaan yang dilakukan untuk masalah tersebut : ....................................
Bagaimana hasilnya ? ................................................................................................
BAYI BARU LAHIR :
Berat badan : .... gram, panjang .... cm, jenis kelamin : L/P (*). nilai APGAR ..../....
Pemberian ASI < 1 jam  ya  tidak, alasan..........................................................................
Bayi lahir pucat/biru/lemas :  mengeringkan  menghangatkan  bebaskan jalan napas
 stimulasi/rangsang taktil  Lain-lain sebutkan.....................
 Cacat bawaan, sebutkan :......................................  hipotermi
 Lain-lain sebutkan :……………………………….
Penatalaksanaan yang dilakukan untuk masalah tersebut :.................................
Bagaimana hasilnya ?............................................................................................

PEMANTAUAN PERSALINAN KALA IV

Jam Ke Waktu Tekanan Nadi Suhu OC Tinggi Kontraksi Kandung Pendarahan
Darah /menit Fundus Uterus Kemih
mmHg uteri

Masalah Kala IV: ......................................................................................................

Penatalaksanaan yang dilakukanan untuk masalah tersebut : ..............................
Bagaimana hasilnya……………………………………................................
(*) coret yang tidak perlu
Analisa Data Kala I
No Tgl/Jam Data Etiologi Masalah
B. DIAGNOSA KEPERAWATAN KALA I
C. RENCANA KEPERAWATAN KALA I
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
D. IMPLEMENTASI KEPERAWATAN KALA I
Hari/tgl/ No. Dx Implementasi Evaluasi Paraf
jam Keperawatan

Hari/tgl/ No. Dx Implementasi Evaluasi Paraf

jam Keperawatan
E. EVALUASI KALA I
Hari/tgl/ No. Dx Evaluasi Paraf
jam Keperawatan
Analisa Data Kala II
No Tgl/Jam Data Etiologi Masalah
B. DIAGNOSA KEPERAWATAN KALA II
C. RENCANA KEPERAWATAN KALA II
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
D. IMPLEMENTASI KEPERAWATAN KALA II
Hari/tgl/ No. Dx Implementasi Evaluasi Paraf
jam Keperawatan

Hari/tgl/ No. Dx Implementasi Evaluasi Paraf

jam Keperawatan
E. EVALUASI KALA II
Hari/tgl/ No. Dx Evaluasi Paraf
jam Keperawatan
Analisa Data Kala III
No Tgl/Jam Data Etiologi Masalah
B. DIAGNOSA KEPERAWATAN KALA III
C. RENCANA KEPERAWATAN KALA III
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
D. IMPLEMENTASI KEPERAWATAN KALA III
Hari/tgl/ No. Dx Implementasi Evaluasi Paraf
jam Keperawatan

Hari/tgl/ No. Dx Implementasi Evaluasi Paraf

jam Keperawatan
E. EVALUASI KALA III
Hari/tgl/ No. Dx Evaluasi Paraf
jam Keperawatan
Analisa Data Kala IV
No Tgl/Jam Data Etiologi Masalah
B. DIAGNOSA KEPERAWATAN KALA IV
C. RENCANA KEPERAWATAN KALA IV
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
Hari/tgl/ Diagnosa Tujuan Intervensi Rasional
jam Keperawatan
D. IMPLEMENTASI KEPERAWATAN KALA IV
Hari/tgl/ No. Dx Implementasi Evaluasi Paraf
jam Keperawatan

Hari/tgl/ No. Dx Implementasi Evaluasi Paraf

jam Keperawatan
E. EVALUASI KALA IV
Hari/tgl/ No. Dx Evaluasi Paraf
jam Keperawatan