Pengkajian Ginekologi
Pengkajian Ginekologi
Kepala
Bentuk : ………………………………………………………………………………
Keluhan : ………………………………………………………………………………
Mata
Ukuran pupil .......................................... Isokor ................................................................
Reaksi terhadap cahaya : …………………………………………………………......
Akomodasi : ……………………………………………………………..
Bentuk : ……………………………………………………………..
Konjunktiva : ……………………………………………………………..
Fungsi penglihatan : ……………………………………………………………..
Tanda-tanda radang : ……………………………………………………………..
Pemeriksaan mata terakhir : ……………………………………………………………..
Operasi : ……………………………………………………………..
Kacamata : ……………………………………………………………..
Lensa kotak : ……………………………………………………………..
Hidung
Reaksi alergi : ……………………………………………………………..
Cara mengatasi : ……………………………………………………………..
Pernah mengalami flu : ……………………………………………………………..
Frekuensi dalam setahun : ……………………………………………………………..
Sinus........................................................ Perdarahan .......................................................
Pernafasan
Suara paru : ……………………………………………………………..
Pola nafas : ……………………………………………………………..
Batuk : ……………………………………………………………..
Sputum : ……………………………………………………………..
Nyeri : ……………………………………………………………..
Kemampuan melakukan aktivitas : ……………………………………………………….
Baruk darah : ……………………………………………………………..
Rontgen terakhir .................................................................................................................
Hasil.....................................................................................................................................
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Sirkulasi
Nadi perifer : ……………………………………………………………..
Capilary refiling : ……………………………………………………………..
Distensi vena jugularis : ……………………………………………………………..
Suara jantung : ……………………………………………………………..
Suara jantung tambahan : ……………………………………………………………..
Irama jantung : ……………………………………………………………..
Nyeri : ……………………………………………………………..
Edema : ……………………………………………………………..
Palpitasi : ……………………………………………………………..
Baal : ……………………………………………………………..
Perubahan warna (kulit, kuk, bibir) : …………………………………………………......
Clubbing : ……………………………………………………………..
Keadaan ekstremitas : ……………………………………………………………..
Syncope : ……………………………………………………………..
Nutrisi
Berat badan................................................ Tinggi Badan………………………………..
Status gizi : ……………………………………………………………..
Jenis diet : ……………………………………………………………..
Nafsu makan : ……………………………………………………………..
Rasa mual : ……………………………………………………………..
Muntah : ……………………………………………………………..
Intake cairan : ……………………………………………………………..
Eliminasi
BAB : ……………………………………………………………..
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Penggunaan pencahar : ……………………………………………………………..
Kolostomi : ……………………………………………………………..
Konstipasi : ……………………………………………………………..
Diare : ……………………………………………………………..
BAK : ……………………………………………………………..
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Pola rutin : ……………………………………………………………..
Inkontinensia : ……………………………………………………………..
Infeksi : ……………………………………………………………..
Hematuri : ……………………………………………………………..
Kateter : ……………………………………………………………..
Urin output : ……………………………………………………………..
Neurosis
Tingkat kesadaran.............................................. GCS.........................................................
Disorentasi : ……………………………………………………………..
Tingkah laku : ……………………………………………………………..
Riwayat epilepsi/kejang/parkinson : ………………………………………………….......
Reflex : ……………………………………………………………..
Muskuloskeletal
Kekuatan otot : ……………………………………………………………..
Pergerakan ekstremitas : ……………………………………………………………..
Nyeri : ……………………………………………………………..
Kekakuan : ……………………………………………………………..
Pola latihan gerak : ……………………………………………………………..
Kulit
Warna : ……………………………………………………………..
Integritas : ……………………………………………………………..
Turgor : ……………………………………………………………..
4. Hubungan/ komunikasi
Bicara……………………………… Bahasa Utama…………………………….....
( ) Jelas
( ) Relevan
( ) Mampu mengekspresikan
( ) Mampu mengerti orang lain
Tempat tinggal ……………………………………………………………………….
( ) Sendiri
( ) Bersama orang lain, yaitu ………………………………………………………..
Kehidupan keluarga ………………………………………………………………….
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Adat istiadat yang dianut ……………………………………………………………
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