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 Pernikahan ..................................................

B. STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................……................
....................................................................................................................................
..........
………………………………………………………………………………………
..…
2. Keluhan utama saat ini : ..................................................................……..................
....................................................................................................................................
..........
…………………………………………………………………………………….
……
3. Riwayat penyakit
sekarang ; ...................................................................................................................
....................................................................................................................................
................
4. Riwayat penyakit dahulu :
....................................................................................................................................
..................................................................................................................................
5. Diagnosa medik : ...........................................................................……....................

C. RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
A. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( )
tidak ( )
 Banyaknya : ............................ Lamanya
: ...........................
 Keluhan : ...........................

1
 B. Riwayat kehamilan, persalinan, nifas yang lalu :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Usia Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan

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 sistem reproduksi :
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 (DI RUMAH DAN DI RS):

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 :
 BAK

3
 - 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

4
 : .............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

5
 pernafasan : ............................................................
 Lainnya
sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ................................................................................
...............
 Kelainan bunyi
jantung : ........................................................................................
 Sakit
dada : ...............................................................................................
 Timbul .: ................................................................................
...............
 Lainnya
sebutkan : ..............................................................................................

Abdomen
 Kondisi : ....................................................................................
............
 Luka bekas
operasi : ...............................................................................................
 Lainnya
sebutkan : ................................................................................................

Genitourinary
 Kebersihan : .....................................................................................
..........
 Perdarahan :
 Vesika
Urinaria : ...............................................................................................
 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: .............................................................................................................
...........................................................................................................................
...........................................................................................................................
..........

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

(..................................................)