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FORMAT PENGKAJIAN GINEKOLOGI


Nama Mahasiswa
Nomor Mahasiswa
Tempat Praktek
Tanggal Praktek

:
:
:
:

I.Identitas diri klien


Nama Klien
:
Tempat Tgl Lahir
;
Umur Klien
:
Jenis Kelamin
:
Alamat
:
Status Perkawinan
:
Agama
:
Suku
:
Pendidikan
:
Pekerjaan
:
Tanggal MRS
:
NO. RM
:
Tanggal Pengkajian
:
Sumber informasi
:
Keluarga yang dapat dihubungi :
Pendidikan
:
Pekerjaan
:
:
II. Status Kesehatan Saat ini
1.Keluhan Utama Saat Ini :
___________________________________________________________________________
___________________________________________________________________________
2. Faktor pencetus :
_________________________________________________________________________
___________________________________________________________________________
3. lamanya keluhan :
__________________________________________________________________________
4. Timbulnya keluhan :
__________________________________________________________________________
__________________________________________________________________________
5. Faktor yang memperberat :

___________________________________________________________________________
___________________________________________________________________________
6. Upaya yang dilakukan untuk mengatasinya :
Sendiri :__________________________________________________________________
___________________________________________________________________________
Oleh orang lain :___________________________________________________________
___________________________________________________________________________
Diagnosa Medik :____________________________________________________________
___________________________________________________________________________

Kesehatan Reproduksi : Kehamilan G P A


No.
Gg.
Proses
Lama
Tempat
Anak Kehami Persalin Persalin Persalin
l
an
an
an
an

Masa
Lah
per
Salin
an

Masala
h
Nifas
Dan
laktasi

Masala
h
bayi

Keada
a
An
anak
Saat
ini

Pemeriksaan payudara:______________________________________________________
keluhan payudara :________________________________________________
Pemeriksaan Genetalia :_____________________________________________________
keluhan genetalia :_________________________________________________
Usia menarche :___________________________________________________________
Usia perkawainan__________________________________________________________
Siklus menstruasi__________________________________________________________
Karakteristik menstruasi ;___________________________________________
Menopause_______________________________________________________________
,keluhan yang muncul selama ini_____________________________________

Masalah

yang

berhubungan

dengan

kesehatan

reproduksi : _________________________
o sejak kapan______________________________________________________
o sudah dilakukan _________________________________________________
Penbedahan_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Pemeriksaan papsmear terakhir________________________________________________
________________________________________________________________________ .
Pemeriksaan payudara sendiri ;_______________________________________________
________________________________________________________________________
III. Riwayat Kesehatan Yang Lalu
1.

Penyakit yang pernah dialami :

a.

Kanak kanak : __________________________________________________

b.

Kecelakaan

c.

Pernah dirawat___________________________________________________

:____________________________________________________

2.

Alergi________________________________________________________________

3.

Imunisasi :____________________________________________________________

4.

Kebiasaan
merokok,kopi,obat
alcohol_____________________________________

_____________________________________________________________________
_____________________________________________________________________
5.
Obat-obatan :___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6.
Pola Nutrisi :
______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___
7.
Pola eliminasi :
a.

Buang Air Besar

_______________________________________________________________
_______________________________________________________________
b.
Buang Air kecil
__________________________________________________________________

dan

__________________________________________________________________
8.

Pola Todur dan Istirahat


_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

9.

Pola Aktifitas dan Latihan

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
10.
Pola bekerja
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
IV. Riwayat Keluarga
Genogram

Riwayat Lingkungan:__________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Aspek psikososial :
1.
Pola pikir dan persepsi:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________
2.

Persepsi diri
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

3.

Suasana hati
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

4.

Hubungan/komunikasi
____________________________________________________________________ ]
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

5.

Kebiasaan Seksual
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

6.

Pertahanan koping
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

7.

Sistem Nilai dan kepercayaan


_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

8.

Tingkat perkembangan
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

VII. Pengkajian Fisik


Tanda Vital : Tekanan darah : ________ mmHg
Nadi
: __________- x/m
Temperatur : __________ C
Respirasi rate : _________ x/m
Berat Badan : _____ kg , Tinggi Badan : _______ cm
Kepala :____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Mata :______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Hidung :___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Mulut dan Tenggorok :________________________________________________________
____________________________________________________________________
Pernafasan
:_________________________________________________________________
__________________________________________________________________
Sirkulasi :__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Nutrisi :____________________________________________________________________
Eliminasi
:__________________________________________________________________
__________________________________________________________________
Genetalia
:__________________________________________________________________
Neurosis :__________________________________________________________________
__________________________________________________________________
Muskuloskeletal
:____________________________________________________________
Kulit :_____________________________________________________________________
.

Tanggal dan jenis


pemeriksaan

Data Laboratorium
Hasil pemeriksaan dan nilai
normal

Interpretasi

Terapi Medis yang diberikan


Tanggal
Jenis terapi

Rute terapi

Hasil pemeriksaan diagnostik lain :

Dosis

Indikasi terapi

Persepsi Klien terhadap penyakitnya :


___________________________________________________________________________

Kesan perawat terhadap klien :


___________________________________________________________________________
___________________________________________________________________________