Anda di halaman 1dari 7

FORMAT PENGKAJIAN

GANGGUAN SISTEM REPRODUKSI


UNIT KEPERAWATAN MATERNITAS
Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :
A. IDENTITAS
1. Nama pasien : ................................. Nama Suami : .....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ...................
4. Agama : ................................. Agama : ...........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status ..................................................
B. STATUS KESEHATAN SAAT INI
1. Alasan kunjungan ke rumah sakit : ....................................................................
................................................................................................................................
................
2. Keluhan utama saat ini : ....................................................................................
................................................................................................................................
...............
3. Timbulnya keluhan : ( ) bertahap, ( ) mendadak
4. Faktor yang memperberat : ...............................................................................
.............................................................................................................
..................................
5. Upaya yang dilakukan untuk mengatasi : .........................................................
................................................................................................................................
...............
6. Diagnosa medik : ...............................................................................................

C. RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
Menarche : umur.................... Siklus : teratur ( ) tidak ( )
Banyaknya : ............................ Lamanya : ...........................
HPHT : ............................ Keluhan : ...........................

b. Riwayat kehamilan, persalinan, nifas yang lalu :


Anak ke Kehamilan Persalinan Komplikasi nifas Anak
No Tahun Umur kehamilan Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan
Jenis BB pj
c. Genogram :
2. RIWAYAT KELUARGA BERENCANA :
Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................

3. RIWAYAT KESEHATAN :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................

4. RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................
.......
- Bahaya :

......................................................................................................................
- Lainnya sebutkan : .................................................................................
.....................
5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. KEBUTUHAN DASAR KHUSUS :
a. Pola Nutrisi
Frekwensi makan : .............................. x sehari
Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : .................................................................................
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
b. Pola eliminasi :
B A K
- Frekwensi : ....................kali
- Warna : ........................
- Keluhan saat BAK : .......................................................................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : ......................
- Keluhan : ..................................................................................
c. Pola personal hygiene
Mandi

- Frekwensi : ...................................x /hari


- Sabun : ( ) ya, ( ) tidak
Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
e. Pola aktifitas dan latihan
Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
Ketergantungan
obat : ..............................................................................................
7. PEMERIKSAAN FISIK
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : ......................................Suhu C: ...............
Berat badan : ......................kg Tinggi badan : ................cm

Kepala, mata kuping, hidung dan tenggorokan :


Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Lainnya sebutkan : .................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Lainnya sebutkan : .................................................................................................
Mulut dan Tenggorokan :
Gigi geligi : .....................................................................................................
Kesulitan menelan : ................................................................................................
Lainnya sebutkan : .................................................................................................
Dada dan Axilla
Mammae : membesar ( ) ya ( ) tidak
Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Menggunakan otot-otot bantu pernafasan : ............................................................
Lainnya sebutkan : .................................................................................................

Sirkulasi jantung
Kecepatan denyut apical : ...............................x/menit
Irama : ...............................................................................................
Kelainan bunyi jantung : ........................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Lainnya sebutkan : ..............................................................................................
Abdomen
Mengecil : ................................................................................................
Linea dan striae : ...............................................................................................
Luka bekas operasi : ...............................................................................................
Kontraksi : ................................................................................................
Lainnya sebutkan : ................................................................................................
Genitourinary
Perineum : ...............................................................................................
Vesika Urinasria : ...............................................................................................
Lainnyasebutkan : ...............................................................................................

Ekstrimitas (integumen/muskuloskeletal)
Turgor kulit : ................................................
Warna kulit : .................................................................................................
Kontraktur pada persendian ekstrimitas : .........................................................
Kesulitan dalam pergerakan : .........................................................................
Lainnya sebutkan : ...........................................................................................

d. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang

didapat: ....................................................................................................................
................................................................................................................................
.........................................................................................................................
e. Data Tambahan
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
............
Surabaya, ........................................
Pemeriksa