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Asuhan Keperawatan Persalinan Normal

Askep Persalinan Normal


Pengertian

Pesalinan normal (partus spontan) adalah proses lahirnya bayi pada letak belakang kepala yang dapat hidup dengan tenaga ibu sendiri dan uri,tanpa alat serta tidak melukai ibu dan bayi yang umumnya berlangsung kurang dari 24 jam melalui jalan lahir.


Pemeriksaan Diagnostik
  • Pemerikaaan darah lengkap
    • Hb normal = 11,4 – 15,1 gr/dl
    • Golangan darah = A,B,AB & O
    • Faktor RH = +/-
    • Waktu pembekuan

  • Protein Urine

  • Urine reduksi


Diagnosa keperawatan
  1. Pola napas tidak efektif berhubungan dengan kelelahan,penggunaan energi berlebihan

  2. Nyeri berhubungan dengan kontraksi rahim & regangan pada jaringan

  3. Penurunan cardiak out put berhubungan dengan peningkatan kerja jantung sekunder penggunaan energi berlebih.


Intervensi
  1. Pola napas tidak efektif b.d penggunaan energi berlebihan

    Tujuan
    Pola napas tidak terganggu/kembali efektif.

    Intervensi :
    • Observasi TTV selama jalannya persalinan
      Rasional : Deteksi dini keadaan klien sehingga dapat dilakukan tindakan secara tepat & cepat.

    • Dampingi klien & berikan dorongan mental selama perslinan
      Rasional : Mengurangi kecemasan sehingga klien dapat mengatur pernapasan scr benar.

    • Ajarkan tehnik pernapasan yg benar saat kontraksi
      Rasional : Meningkatkan cadangan oksigen & tenaga

    • Ajarkan cara mengedan yg benar
      Rasional : Agar klien dpt menghemat energi & melahirkan bayinya dng cepat.

  2. Nyeri b.d kontraksi rahim & regangan jaringan

    Tujuan
    Nyeri berkurang/hilang.

    Intervensi :
    • Observasi skala nyeri dng skala 1 – 10, intensitas & lokasi
      Rasional : Mengetahui tingkat nyeri & ketergantungan klien serta kualitas nyeri

    • Ajarkan tehnik relaksasi & menarik napas panjang
      Rasional : Meningkatkan relaksasi & rasa nyaman

    • Berikan penjelasan ttg penyebab nyeri & kapan hilangnya
      Rasional : Meningkatkan pengetahuan sehingga mengurangi kecemasan,klien menjadi kooperatif

    • Ajarkan cara mengedan yg benar jika pembeukaan sudah lengkap
      Rasional : Mengurangi kelelahan & mempercepat proses persalinan.

    • Anjurkan klien u/ istirahat miring kiri jika tdk sedang kontraksi
      Rasional : Mengurangi penekanan vena cava, meminimalkan hipoksia jaringan.

  3. Penurunan Cardiak output b.d peningkatan kerja jantung

    Tujuan
    Cardiak out put dalam batas normal, TD= 120/80 mmHg,Nadi=80 x/mnt

    Intervensi
    • Observasi TTV
      Rasional : Mengetahui perkembangan/perubahan yg terjadi pada klien

    • Observasi perubahan sensori
      Rasional : Mengetahui ketidak adekuatan perfusi cerebral.

    • Observasi penggunaan energi & irama jantung
      Rasional : Mengetahui tingkat ketergantungan klien.


Daftar Pustaka

Bagian Obstetri & Ginekologi,FK.Unpad. 1993. Obstetri. Elstar. Bandung.
Carpenito,Lynda Juall. 2001 Buku Saku Diagnosa Keperawatan. ed.8.EGC. Jakarta
Prawiro Harjo. 1995. Bedah Kebidanan. Bina Pustaka. Jakarta
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