ASUHAN KEPERAWATAN IBU DENGAN GANGGUAN

SISTEM REPRODUKSI

......................................................................................................................................................
Tanggal / Jam MRS :
Pengkajian
Tanggal :
Jam :
Tempat :

A. DATA SUBYEKTIF
1. IDENTITAS
Nama : Nama Suami :

Umur : Umur :

Agama : Agama :

Pendidikan : Pendidikan :

Pekerjaan : Pekerjaan :

Penghasilan : Penghasilan :

Alamat : Alamat :

No Reg :

Diagnosa Medis : ....................................................................................................................................................................

2. KELUHAN
a. Saat MRS
.............................................................................................................................................................................................
................................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................

b. Saat Pengkajian (Keluhan Utama)

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

3. RIWAYAT KESEHATAN
3.1 Penyakit yang lalu
...............................................................................................................................................................................................
...............................................................................................................................................................................................
3.2 Penyakit sekarang
..............................................................................................................................................................................................
...............................................................................................................................................................................................
3.3 Penyakit Keluarga
................................................................................................................................................................................................
................................................................................................................................................................................................
...............................................................................................................................................................................................

4. RIWAYAT OBSTETRI / KEBIDANAN

4.1 Riwayat Menstruasi
Amenorhea :........................................................... Teratur/tdk : .....................................................................
Menarche :.......................................................... Dismenorhea: .....................................................................
Lama :.......................................................... Flour Albus : .....................................................................
Banyak : ........................................................
Siklus :.........................................................

5. RIWAYAT KEHAMILAN,PERSALINAN DAN NIFAS YANG LALU

No Tgl/Bln/Thn Usia Tempat Jenis Penolong Penyulit Anak Nifas Usia Hidup/
(Gravida) Persalinan Kehamilan Persalinan Persalinan JK BB PB anak Mati
 6. RIWAYAT KB

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

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

7. RIWAYAT PERNIKAHAN

Usia....................berapa kali.................................

Jarak perkawinan & kehamilan pertama................................................th.

Usia anak terakhir.....................th

8. RIWAYAT PSIKOSOSIAL SPIRITUAL & KELUARGA

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

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

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

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

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

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

9. POLA AKTIFITAS

Kebutuhan Dasar Sebelum MRS Saat MRS

1. Cairan & Makanan

2. Eliminasi

3. Istirahat & Tidur

 4. Personal hygiene

5. Aktivitas

6. Pola Sexualitas

B. DATA OBJEKTIF

1. KEADAAN UMUM :

- Kesadaran :............................................................................................................................................

- TTV : TD : N: S:

RR : SPO2 :

- TB :...........................................................................................................................................

- BB (sebelum & saat hamil) :............................................................................................................................................

2. PEMERIKSAAN FISIK

a. Pemeriksaan Kepala ( Inspeksi, Palpasi)

- Rambut :............................................................................................................................................................

- Wajah :...........................................................................................................................................................

- Mata :...........................................................................................................................................................

- Hidung :..........................................................................................................................................................

- Mulut :............................................................................................................................................................

- Telinga :............................................................................................................................................................

b. Pemeriksaan Leher :...........................................................................................................................................................

c. Pemeriksaan Thorax (Inspeksi, Palpasi, Auskultasi)

- Payudara

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

................................................................................................................................................................................................
 - Jantung

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

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

- Paru

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

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

d. Pemeriksaan Abdomen (Inspeksi, Palpasi, Auskultasi)

Inspeksi :............................................................................................................................................................................

Palpasi :

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

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

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

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

Auskultasi : :.........................................................................................................................................................................

e. Pemeriksaan Ekstremitas

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

f. Pemeriksaan Genetalia

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

g. Pemeriksaan Integumen

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

h. Pemeriksaan Dalam

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

1. PEMERIKSAAN PENUNJANG

a. Laboratorium/USG

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

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

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

b. Radiologi

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

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

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

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

2. TERAPI

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

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

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

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