FORMAT PENGKAJIAN

PADA WANITA DENGAN GANGGUAN SISTEM REPRODUKSI

DATA SUBJEKTIF

1. Identitas/biodata
Nama :

Umur :

Suku/Bangsa :

Agama :

Pendidikan :

Pekerjaan :

Alamat Rumah :

Telepon :

2. Keluhan Utama
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

3. Riwayat Kehamilan & Persalinan yang lalu G........ P....... A.......

No Tangga Tempat Usia Jenis penolon Penyakit Anak
. l Lahir kehamilan kehamilan g kehamilan JK BB TB Keadaan
& persalinan
4. Riwayat Kesehatan
Penyakit yang pernah/sedang diderita
No. Jenis Sekarang Dahulu
1. Jantung
2. Hipertensi
3. Hepatitis
4. DM
5. Anemia
6. PMS
7. TBC
8. Malaria
9. Gangguan Mental
10. Operasi
11. Lain-lain
Keturunan Kembar : ada/tidak : .......................Dari pihak : ....................

5. Pola fungsi kesehatan

a. Aktivitas sehari-hari
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
b. Pola nutrisi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

c. Pola eliminasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
d. Pola tidur dan istirahat
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
e. Pola hygiene
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

6. Riwayat Kontrasepsi
Pernah menggunakan kontrasepsi jenis ................................... lamanya.........................
Alasan berhenti ...............................................................................................................
Ganti cara ................................................................................. sejak..............................
Alasan .............................................................................................................................
Status perkawinan sah : ...............................Istri ke .........................................
7. Riwayat Menstruasi
Menarche : .....................................
Lamanya : .....................................
Sifat darah : .....................................
Flour albus: .....................................
Siklus : ..........................................
Jumlah : ..........................................
Dismenorhea : .................................

DATA OBJEKTIF

PEMERIKSAAN FISIK

1. Keadaan umum & tingkat kesadaran:

................................................................................................................................................
...............................................................................................................................................

2. Tanda-tanda Vital
Respirasi :.................x/menit Nadi :................x/menit

Tekanan darah :.................mmHg Suhu :................°C

3. BB sebelumnya : ...........kg
BB sekarang : ...........kg

TB : ...........cm

4. Rambut
................................................................................................................................................
................................................................................................................................................
5. Muka
................................................................................................................................................
...............................................................................................................................................

6. Mata
................................................................................................................................................
................................................................................................................................................

7. Hidung
................................................................................................................................................
...............................................................................................................................................

8. Telinga
................................................................................................................................................
................................................................................................................................................
 9. Leher
................................................................................................................................................
................................................................................................................................................

10. Dada
................................................................................................................................................
................................................................................................................................................

11. Mammae
................................................................................................................................................
................................................................................................................................................

12. Abdomen
................................................................................................................................................
................................................................................................................................................

13. Genitalia
Inspeksi : .........................................

Inspekulo : .........................................

VT : .........................................

14. Ekstremitas atas : ..............................................................................................

Ekstremitas Bawah : ..............................................................................................

Udema : ..............................................................................................

Varises : ..............................................................................................

PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium
Tanggal : ............................................
Darah
................................................................................................................................................
.......................................................................................................................

Urine
................................................................................................................................................
.......................................................................................................................
Pemeriksaan penunjang lainnya
Pap Smear : .........................................................................................................
USG/Rongent : .........................................................................................................
Mammografi : .........................................................................................................
Lain-lainnya : .........................................................................................................
.........................................................................................................
 ........................., .............................

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