FORMAT PENGKAJIAN KEPERAWATAN

STASE KEPERAWATAN MATERNITAS (Ginekologi)

(Klasifikasi Gordon)

Tanggal : ………………………… Nama Mahasiswa : ……………………….

I. DATA DASAR PASIEN

Nama Klien : .................................................................. Umur : ......................................

Tanggal Masuk RS : ....................................................... No. Reg : ..................................

Jenis Kelamin : .............................................................. Pekerjaan : ................................

Alamat : .......................................................................... Agama: .....................................

Status Perkawinan : ........................................................

Pendidikan : ................................................................... Suku : .......................................

Sumber Pembiayaan : .................................................... Penanggung Jawab : .................

Diagnosa medis saat masuk RS : ....................................

Tanggal Pengkajian : ...................................................... Sumber Informasi : .................

Diagnosa medis saat ini (saat pengkajian) : ........................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama :

a. Keluhan Utama Saat Masuk Rumah Sakit :

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b. Keluhan Utama Saat Pengkajian :

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2. Riwayat Kesehatan/ Penyakit Sekarang :

a. Alasan kunjungan (Yang membuat klien datang ke pelayanan kesehatan) :

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b. Faktor pencetus (yang menyebabkan pasien merasa sakit/kurang sehat) :

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c. Lama keluhan (berapa lama klien merasakan sakit/kurang sehat) Alasan klien

tidak segera pergi ke pelayanan kesehatan :

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d. Timbul keluhan :

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e. Faktor yang memperberat (hal-hal yang membuat sakit klien terasa semakin

parah) :

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f. Upaya yang dilakukan untuk mengatasinya (mengatasi keluhan) ?

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g. Pemeriksaan penunjang yang telah dilakukan (Tgl, jenis pemeriksaan, hasil,

nilai normal) :

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3. Riwayat kesehatan/Penyakit dahulu :

a. Penyakit yang pernah dialami (Sakit apa, kapan terjadi, upaya yang dilakukan,

tempat dirawat, pernah operasi atau tidak) :

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

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b. Riwayat alergi (jika ada sebutkan tipe alergi, reaksi dan tindakan yang

dilakukan) :

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c. Riwayat imunisasi TT (Lengkap atau tidak, sebutkan) :

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d. Kebiasaan : merokok/minum kopi/konsumsi obat/alkohol/lain-lain :

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e. Obat-obatan yang dikonsumsi saat ini:

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

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f. Riwayat kesehatan/penyakit keluarga (buat GENOGRAM) :

III. TANDA-TANDA VITAL

Blood Pressure : .................................................................................................

Respirasi : ..........................................................................................................

Pulse : ................................................................................................................

Temperature : ....................................................................................................

Berat Badan : .....................................................................................................

Tinggi Badan : ...................................................................................................

IV. POLA MANAJEMEN KESEHATAN

1. Pola Persepsi Kesehatan-Managemen kesehatan

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2. Pola Metabolik Nutrisi

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3. Pola Eliminasi

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4. Pola Aktivitas dan latihan (olahraga)

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5. Pola Istirahat dan tidur

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6. Pola Persepsi - Kognitif

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7. Pola Konsep Diri - Persepsi Diri

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8. Pola Hubungan – Peran

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9. Pola Reproduksi – seksualitas

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10. Pola Toleransi Terhadap Stress – Koping

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11. Pola Keyakinan – Nilai

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V. Pemeriksaan Fisik

1. Kepala : ............................................................................................................

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2. Mata : ............................................................................................................
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3. Telinga : ............................................................................................................

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4. Hidung : ............................................................................................................

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5. Mulut : ............................................................................................................

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6. Tenggorokan : ............................................................................................................

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7. Leher : ............................................................................................................

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8. Dada : ............................................................................................................

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9. Paru-paru : ...........................................................................................................

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10. Jantung : ............................................................................................................

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 11. Abdomen : ............................................................................................................

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12. Kulit : ............................................................................................................

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13. Genetalia : ............................................................................................................

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VI. Pemeriksaan Penunjang

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 Pengelompokan Data

Data Subjektif

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Data Objektif

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 Analisa Data

No Data Etiologi Problem

 RENCANA KEPERAWATAN
Diagnosa Keperawatan
No NOC NIC
NANDA
 TINDAKAN KEPERAWATAN
No Tgl/Jam Pkl Implementasi Respon Klien Paraf
 EVALUASI KEPERAWATAN
No Hari/Tgl PKL No. Dx Evaluasi Paraf