YAYASAN KARUNIA ABADI

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

INSAN UNGGUL SURABAYA
Kampus : Jl. Raya Kletek, No.4 Sidoarjo, Telp. (031) 7860630; Fax. (031) 7860630

FORMAT PENGKAJIAN
ASUHAN PADA PASIEN IBU DENGAN GANGGUAN SISTIM REPRODUKSI

Nama Fasilitator : Nama Mahasiswa :

Nilai : NIM :

Tanggal MRS : Jam :

No. Register : Tempat/ Tgl Pengkajian :

1. PENGKAJIAN
1.1. ANAMNESE
1.1.1. BIODATA
1. Identitas Pasien/ Klien
a. Nama Pasien : ................................. a. Nama Suami : ..................................
b. Umur : ................................. b. Umur : ..................................
c. Suku/ Bangsa : ................................. c. Suku/ Bangsa : ..................................
d. Agama : ................................. d. Agama : ..................................
e. Pendidikan : ................................. e. Pendidikan : ..................................
f. Pekerjaan : ................................. f. Pekerjaan : ..................................
g. Status Marital : ................................. g. Alamat : ..................................
h. Alamat : ................................. ...............................................................
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2. Penanggung Jawab Klien / Pasien
a. Nama Lengkap : ..............................................................................................
b. Hubungan Dengan Klien : ..............................................................................................
c. Tempat / Tanggal Lahir : ..............................................................................................
d. Pendidikan / Pekerjaan : ..............................................................................................
e. Alamat & No. Telp : ..............................................................................................
1.1.2. STATUS KESEHATAN SAAT INI
1) Keluhan Utama / Alasan Kunjungan ke Rumah Sakit / Puskesmas
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 2) Upaya yang Dilakukan untuk Mengatasi Keluhan
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1.1.3. RIWAYAT OBSTETRI
1. Riwayat Menstruasi :
a. Menarche : Umur ....................................................................................
b. Siklus :( ) Teratur ( ) Tidak Teratur
c. Lamanya : ..............................................................................................
d. Banyaknya : ..............................................................................................
e. Keluhan : ..............................................................................................
f. HPHT : ..............................................................................................

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 2. Riwayat Kehamilan, Persalinan, Nifas yang lalu
Kehamilan Persalinan Komplikasi Nifas Anak
No Umur
Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan jenis BB PB
Kehamilan

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1.1.4. RIWAYAT KELUARGA BERENCANA
1) Pernah Memakai Kontrasepsi :
Ya
Tidak
2) Jenis Kontrasepsi yang Dipakai : ..................................................................................
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3) Sejak Kapan Menggunakan Kontrasepsi : ......................................................................
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4) Keluhan yang Dialaminya : ..................................................................................
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1.1.5. RIWAYAT KESEHATAN
1) Penyakit yang Pernah Dialami : ..................................................................................
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2) Pengobatan yang didapat : ..................................................................................
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3) Riwayat Penyakit Keluarga : ..................................................................................
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1.1.6. ASPEK PSIKOSOSIAL
1) Persepsi Ibu Terhadap Keluhan / Kehamilan
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2) Harapan yang Ibu Inginkan
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3) Sikap Anggota Keluarga Terhadap Keadaan Saat Ini
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1.1.7. KEBUTUHAN DASAR KHUSUS
1) Pola Nutrisi : ..............................................................................................
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2) Pola Eliminasi : ..............................................................................................
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3) Personal Hygiene : ..............................................................................................
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4) Istirahat Tidur : ..............................................................................................
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5) Aktifitas dan Latihan : ..............................................................................................
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6) Kebiasaan yang Mempengaruhi Kesehatan :
a. Merokok : ..............................................................................................
b. Jamu : ..............................................................................................
c. Obat : ..............................................................................................
d. Minuman Keras : ..............................................................................................
1.2. PEMERIKSAAN FISIK
1.2.1. Tanda-tanda Vital :
1. Kesadaran : ..............................................................................................
2. Tensi : ..............................................................................................
3. Nadi : ..............................................................................................
4. Respirasi : ..............................................................................................
5. Suhu : ..............................................................................................
1.2.2. Antropometri :
1. Berat Badan : ..............................................................................................
2. Tinggi Badan : ..............................................................................................
3. Lingkar Lengan : ..............................................................................................
1.2.3. Pemeriksaan Secara Umum:
1. Kepala :
a. Bentuk : ..............................................................................................
b. Mata : ..............................................................................................
c. Telinga : ..............................................................................................
d. Hidung : ..............................................................................................
e. Tenggorokan : ..............................................................................................
2. Mata :
a. Kelopak Mata : ..............................................................................................
b. Gerakan Mata : ..............................................................................................
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 c. Konjungtiva : ..............................................................................................
d. Sklera : ..............................................................................................
e. Pupil : ..............................................................................................
f. Akomodasi : ..............................................................................................
g. Lainnya : ..............................................................................................
3. Hidung :
a. Reaksi Alergi : ..............................................................................................
b. Sinus : ..............................................................................................
c. Lainnya : ..............................................................................................
4. Mulut :
a. Kebersihan : ..............................................................................................
b. Gigi : ..............................................................................................
5. Dada dan Axilla :
a. Mammae Membesar : ( ) Ya ( ) Tidak
b. Areolla Mammae : ..............................................................................................
c. Papilla Mammae : ..............................................................................................
d. Colostrum : ..............................................................................................
6. Pernafasan :
a. Frekuensi : ..............................................................................................
b. Suara Nafas : ..............................................................................................
c. Menggunakan otot bantu pernafasan : ......................................................................
7. Sirkulasi Jantung :
a. Kecepatan Denyut Jantung : ..................................................................... X/ Menit
b. Suara Jantung : ..............................................................................................
8. Abdomen :
a. Pembesaran : ..............................................................................................
b. Linea & Striae : ..............................................................................................
c. Luka Bekas Operasi : ..............................................................................................
d. Kontraksi : ..............................................................................................
e. Lainnya : ..............................................................................................
9. Genitourinary :
a. Perineum : ..............................................................................................
b. Vesika Urinaria : ..............................................................................................
c. Lainnya : ..............................................................................................
10. Ekstremitas :
a. Turgor Kulit : ..............................................................................................
b. Warna Kulit : ..............................................................................................
c. Pergerakan pada Persendian Ekstremitas : ...............................................................

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1.3. DATA PENUNJANG
1. Laboratorium : .........................................................................................
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2. USG : .........................................................................................
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3. Rontgen : .........................................................................................
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1.4. TERAPI
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1.5. DATA TAMBAHAN
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Mengetahui ......................, Tgl……………………..

CI / Ka. Ruangan Pemeriksa

(………………………………………….) (………………………………………….)

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 ANALISA DATA
No. Tgl/ Jam Data Penyebab Masalah

Diagnosa Keperawatan
1. ..............................................................................................................................................
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2. ..............................................................................................................................................
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3. ..............................................................................................................................................
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 RENCANA KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tujuan Intervensi Rasional

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 IMPLEMENTASI KEPERAWATAN
Nama / Inisial Pasien : …………………………
No RM : …………………………
Diagnosa Medis : …………………………
No Diagnosa Tgl/ Jam Implementasi Tgl/ Jam Evaluasi

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 CATATAN PERKEMBANGAN

No. Hari/ Tgl Diagnosa Catatan Perkembangan (SOAPI)

Mengetahui ………………., Tgl ………………………

CI/ Ka. Ruangan Penyusun

( ………………………………………….) ( ………………………………………….)

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