DEPARTEMEN PENDIDIKAN NASIONAL

PROGRAM STUDI ILMU KEPERAWATAN

FK UNAIR SURABAYA
FORMAT PENGKAJIAN
GANGGUAN SISTEM REPRODUKSI
UNIT KEPERAWATAN MATERNITAS
Tanggal masuk
Ruang/kelas
Pengkajian tanggal
1.

:
:
:

Jam masuk
Kamar No
Jam

IDENTITAS
1.
Nama pasien : .................................
.....................
2.
Umur
: ....................... th
: ....................... th
3.
Suku/ bangsa : .................................
...................
4.
Agama
: .................................
: ...........................
5.
Pendidikan
: ..................................
: ...........................
6.
Pekerjaan
: ..................................
: ...........................
7.
Alamat
: ..................................
: ...........................
8.
Status ..................................................

:
:
:
Nama Suami :

Umur
Suku/ bangsa :
Agama
Pendidikan
Pekerjaan
Alamat

2. STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ..............................................................
.....

3.

2.

Keluhan
utama
saat
ini
:
.............................................
..........................................

3.

Timbulnya keluhan : (

4.

Faktor yang memperberat : .........................................................................

......

5.

Upaya yang dilakukan untuk mengatasi : ............................................

...............

6.

Diagnosa
medik
:
.......................................
........................................................

) bertahap, (

RIWAYAT KEPERAWATAN

) mendadak.

1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :

Menarche
: umur....................
) tidak ( )

Banyaknya
: ............................
: ...........................

HPHT
: ............................
: ...........................

Siklus
Lamanya
Keluhan

: teratur (

b. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke
Kehamilan
Persalinan
No

Tahun

c. Genogram :

Umur
kehamilan

Penyulit

Jenis

Penolong

Komplikasi nifas
Penyulit

Laserasi

Infeksi

Perdarahan

Anak
Jenis

BB

pj

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
ibu : ........................................................................

Pengobatan
didapat : ......................................................................................

Riwayat penyakit keluarga

( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya
:
sebutkan ......................................................................

dialami
yang

4. RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................
.......
- Bahaya
:
......................................................................................................................
- Lainnya sebutkan :
.................................................................................
.....................
5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan seharihari ?............
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
alasan ..........................................

Jenis
rumah : .................................................................................

Makanan
yang
tidak
disukai/
pantangan : .............................................
b. Pola eliminasi :

nafsu,
makanan
alergi/

BAK
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
: .................................................................................................
Rontgen
: .....................................................................................

3)
............
4)

Terapi
yang
didapat : ............................................................................................................
...........................................................................................................................
...........................................................................................................................
...............

e. Data Tambahan
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Surabaya, ........................................
Pemeriksa

( Subhan.)