I. Pengkajian
Tanggal : Jam :
No. RM :
Nama : Nama Suami :
Umur : Umur :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat : Alamat :
Cara masuk :
Diagnose :
A. DATA SUBYEKTIF
1. Keluhan
utama : ....................................................................................................................................
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...........
2. Riwayat menstruasi
Usia manarche :
Jumlah darah haid :
HPHT :
Keluhan saat haid :
Lama haid :
Flour albus :
TP :
Keluhan haid :
Dll..............
9. Riwayat Ginekologi :
Infertilitas Infeksi virus PMS Endometritis
Polip serviks Kanker kandungan Operasi kandungan Perkosaan
DUB dll........................
- Pola eliminasi :
BAK.................cc/hari, warna : jernih/kuning/kuning pekat/ groshematuri, BAK terakhir
jam :.........
BAB..................kali/hari, karakteristik: lembek/keras, BAB terakhir jam :.........................
- Pola istirahat : ............................jam/hari, tidur terakhir jam : ...................
- Dukungan keluarga : Suami Orang tua Mertua Keluarga lain
B. DATA OBYEKTIF
1. Pemeriksaan umum
Keadaan umum : Kesadaran :
BB/TB : Tekanan Darah:
Nadi : Suhu :
Pernafasan :
2. Pemeriksaan Fisik
- Mata : Konjungtiva : anemis/tidak Selera : Ikterik/tidak
Pandangan Kabur Adanya pemandangan dua
- Rahang, gigi, gusi : normal/tidak, gusi berdaarah/tidak
- Leher : adanya pembesaran vena jugularis / tidak, adanya pembesaran kelenjar
thyroid/tidak.
- Dada : aerola hiperpigmentasi Tumor Kolostrum
Puting susu menonjol/masuk ke dalam
- Axilla : adanya pembesaran kelenjar limfe/tidak
- Sistem respiratori : dispneu tachipneu wheezing batuk
- Sistem kardio : Nyeri dada murmur palpitasi
- Pinggang :nyeri/tidak, skoliosis, lordosis, kiposis(coret yang tidak perlu)
- Ekstrimitas atas dan bawah : tungkai simetris/asimetris oedema
Reflek patella varises
3. Pemeriksaan khusus
a. Abdomen
Inspeksi membesar dengan arah memanjang melebur
Pelebur vena linea alba linea agra strie livide
Strie albican luka bekas operasi lain-lain
b. TFU : .............................., Kontraksi Uterus : Baik/lembek
Diastesis rectus abdomonis : +/-, ............................
Kandung kemih : Kosong/ penuh
Vulva Vagina : Lochea.................., Bau +/-
Luka Jalan lahir : Ruptur/Episiotomi, bengkak/tidak, bersih/kotor, luka
jahitan bertaut/tidak, basah/kering
Tanda-tanda Reeda (Red, Echimosis, Edema, Discharge, Aproximal)
Ekstremitas : Tromboflebitis (ada/tidak, berapa lama....................)
4. Pemeriksaan laboratorium :
- Laboratorium lengkap.
- USG : ...........................................
C. ANALISA
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D. PENATALAKSANAAN
Tanggal : ....................................................... Jam : ..........................
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Kediri,............................
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NIP. NIM.
Dosen Pembimbing
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NIP.