POLITEKNIK KESEHATAN KEMENKES BANDUNG

PROGRAM STUDI KEBIDANAN KARAWANG

Jalan kertabumi No.74

DOKUMENTASI KESEHATAN REPRODUKSI

No. Register :………….. Tanggal Pengkajian : …………..

Nama Pengkaji : ………….. Tempat Pengkajian : …………..

1. DATA SUBJEKTIF( S)
A. Biodata
Nama : …………………………………………………….
Umur : ……………………………………………………..
Alamat : …………..…………………....................................
…………..…………………....................................

B. Keluhan utama : …………..…………………....................................

…………..………………….....................................

C. Riwayat Menstruasi
Siklus haid : hari lamanya haid :.........hari,teratur/tidak teratur
Dismenore : ada/tidak Banyaknya : .......x ganti pembalut/hari

D. Riwayat KB
1. Jenis :
2. Lama pemakaian :
3. Keluhan :

E. Riwayat Kesehatan
1. Riwayat kesehatan yang sedang diderita :
2. Riwayat kesehatan yang pernah diderita :
3. Riwayat Operasi :

F. Pola kebiasaan sehari- hari :

1. Pola Nutrisi : …………..…………………....................
2. Pola Aktivitas seksual : …………..…………………....
3. Riwayat pekawinan : …………..………………….....
II. DATA OBJEKTIF (O)
1. Keadaan umum :......... kesadaran :................. status emosional :.....................
2. Tanda –tanda vital
TD :................... Nadi :.............
Respirasi : .................. Suhu :.............
BB : …………..
3. Pemeriksaan Fisik
 Muka
Inspeksi
 Oedema :
 Pucat atau tidak :
Palpasi
 Oedema :
 Mata :
 Leher
 Pembengkakan kelenjar tyroid : ya/tidak
 Pembengkakan KGB : ya /tidak
 Pembengkakan vena jugularis : ya/tidak
 Dada
Payudara
Inspeksi : simetris /tidak :
Benjolan :
Hypergimentasi :
Palpasi : Benjolan :
Puting susu :
Colostrum :
Pemeriksaan KGB Axilla :
Kelainan : Retraksi :
Lecet :
 Abdomen
Inspeksi
 Bentuk perut :
 Sikatrik bekas operasi :
 Strial :
 Hypergimentasi :
Palpasi
Pembesaran Hepar :
Pembesaran limfe :
 Ekstremitas atas :
  Ekstremitas bawah :
 Genetalia :
4. Pemeriksaan penunjang
PP test :
III. ASSESMENT (A)
Diagnosa : ……………………………………………………………………..
……………………………………………………………………...

Masalah : …………………………………..………………………………...
Kebutuhan : ……………………………………………………………….........

IV. PENATALAKSANAAN (P)

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