FORMAT PENGKAJIAN

GANGGUAN REPRODUKSI

Nama mahasiswa : …………………………………….

NIM : …………………………………….
Tanggal pengkajian : …………………………………….
Ruangan/ RS/ PKM : …………………………………….
Tgl/Jam MRS : …………………………………….
Diagnosa Medis : …………………………………….
No Register : …………………………………….

I. BIODATA
Nama Klien : ……………………… Nama Klien : ……………………………..
Umur : ……………………… Umur : ……………………………..
Suku/ Bangsa : …………………….. Suku/ Bangsa : ……………………………...
Pendidikan : ……………………… Pendidikan : …………………………….
Pekerjaan : …………………….. Pekerjaan : …………………………….
Agama : …………………….. Agama : ……………………………..
Penghasilan : …………………….. Penghasilan : ……………………………..
Gol. Darah : …………………….. Gol. Darah : ……………………………..
Alamat : …………………….. Alamat : …………………………….
Kehamilan : ……………………..

II. RIWAYAT KESEHATAN

1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat penyakit dahulu

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4. Riwayat Kesehatan Keluarga
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5. Riwayat Psikososial
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6. Pola-pola fungsi kesehatan
a. Pola persepsi & tata laksana hidup sehat
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b. Pola nutrisi & metabolisme
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c. Pola aktivitas
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d. Pola eliminasi
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e. Pola persepsi sensoris
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f. Pola konsep diri
 Identitas diri:
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 Peran diri:
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 Gambaran diri:
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 Harga diri:
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 Ideal diri:
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g. Pola hubungan & peran

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h. Pola reproduksi & seksual
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i. Pola penanggulangan stres/ koping- toleransi stres
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7. Riwayat pengkajian obstetri, prenatal dan intranatal

a. Riwayat menstruasi
 Menarche : ………………………………………………………………
 Lamanya : ………………………………………………………………
 Siklus : ………………………………………………………………
 Haid pertama haid terakhir : ………………………………………………………………
 Dismenorhoe : ………………………………………………………………
 Fluor albus : ………………………………………………………………
 Menopause : ………………………………………………………………
b. Riwayat perkawinan
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c. Riwayat kehamilan dan persalinan
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d. Riwayat keluhan obstetric

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e. Riwayat penggunaan kontrasepsi
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8. Riwayat Ginekologi
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9. Pemeriksaan fisik (inspeksi, palpasi, auskultasi, perkusi)
a. Keadaan Umum:
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b. Tanda- tanda vital
 Tekanan Darah :
 Nadi :
 Respirasi :
 Suhu :
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 Tinggi badan :

c. Kepala & leher

Inspeksi
1) Kepala :
2) Muka :
3) Mata :
4) Hidung :
5) Mulut :
6) Telinga :
7) Leher :
Palpasi
 Kepala :

 Leher :
d. Thorax/ dada
Paru
1) Inspeksi
2) Palpasi
3) Perkusi
4) Auskultasi
Jantung
1) Inspeksi
2) Palpasi
3) Perkusi
4) Auskultasi

e. Pemeriksaan payudara
Inspeksi
 Palpasi

f. Abdomen
1) Inspeksi

2) Auskultasi

3) Palpasi

4) Perkusi

g. Genetalia dan anus

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h. Punggung
Inspeksi

Palpasi

i. Ekstremitas
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j. Integumen
III. Pemeriksaan laboratorium
Urine
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Feses
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IV. Pemeriksaan diagnostik lain
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.......................................,2019

Pemeriksa