PROFESI KEPERAWATAN MATERNITAS

PROGRAM STUDI PROFESI NERS

STIKES ICME JOMBANG
2017

ASUHAN KEPERAWATAN GINEKOLOGI

A. PENGKAJIAN
1. Identitas diri klien
Nama :
Usia :
Jenis Kelamin :
Alamat :
Pendidikan :
Tanggal masuk RS :
Tanggal pengkajian :
No Register :
Diagnosa medis :
Penanggung jawab
Nama :
Usia :
Alamat :
Hubungan dengan klien:

2. Status kesehatan saat ini

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3. Riwayat keluarga
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Gambar genogram:

4. Riwayat kesehatan yang lalu

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5. Pemeriksaan fisik dan keluhan fisik yang dialami

a. Keadaan umum :
Vital sign
Tekanan darah :
Nadi :
Suhu :
Pernafasan :
b. Kepala
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c. Mata
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d. Hidung
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e. Mulut dan tenggorokan
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f. Sirkulasi
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g. Nutrisi
- Berat badan
- Tinggi badan
- Status gizi:
IMT :
Penampilan klinis : Klien tampak lemas
- Diet:
Sebelum sakit :
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Saat hospitalisasi:
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- Cairan .
Tanggal Intake (selama 4 jam) Outake (selama 4 Balance
jam) Cairan
6 Januari Infus : Urine :
2016 Minum : IWL :
Air makanan:
Total : Perdarahan :
Total :

h. Eliminasi
1) BAK
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2) BAB
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i. Reproduksi
No Gangguan Proses Lama Tempat Masalah Masalah Masalah Keadaan
Anak Kehamilan persalinan persalinan persalinan persalinan nifas bayi anak
saat ini

j. Pemeriksaan payudara
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 k. Pemeriksaan genitalia
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l. Neurologi
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m. Muskuloskeletal
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n. Kulit
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6. Psikososial
a. Pola pikir dan persepsi
1) Alat bantu yang digunakan:
( ) kacamata
( ) alat bantu pendengaran
b. Persepsi diri
1) Hal yang sangat dipikirkan saat ini:
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2) Harapan setelah menjalani perawatan:
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3) Perubahan yang dirasa setelah operasi:
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4) Hubungan/komunikasi
 a) Bicara Bahasa utama:
( ) jelas
( ) relevan
( ) mampu mengekspresikan
( ) mampu mengerti orang lain
b) Tempat tinggal
( ) sendiri
( ) bersama orang lain:
Kehidupan keluarga
a) Adat istiadat yang dianut :
b) Pembuat keputusan dalam keluarga:
c) Pola komunikasi :
d) Keuangan:
( ) memadai
( ) kurang
e) Kesulitan dalam keluarga:
5) Kebiasaan seksual
a) Gangguan hubungan seksual disebabkan kondisi sebagai
berikut:
( ) fertilitas ( ) menstruasi ( ) libido
( ) kehamilan ( ) ereksi
( ) alat kontrasepsi
b) Pemahaman terhadap fungsi seksual
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c) Masalah seksual yang dialami:
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6) Pertahanan koping
a) Pengambil keputusan
( ) sendiri
 ( ) dibantu orang lain yaitu suami
b) Yang disukai tentang diri sendiri :
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c) Yang ingin diubah dari kehidupan:
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d) Yang dilakukan pada saat stres:
( ) pemecahan masalah
( ) makan
( ) tidur
( ) makan obat
( ) cari pertolongan
( ) lain-lain misalnya diam
e) Apa yang dilakukan oleh perawat agar anda nyaman dan
aman:
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7) Sistem nilai kepercayaan
a) Siapa atau sumber kekuatan:
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b) Apakah Tuhan, agama, kepercayaan penting untuk anda: ........
c) Kegiatan agama atau kepercayaan yang dilakukan (macam dan
frekuensi):
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d) Kegiatan agama dan kepercayaan yang ingin dilakukan selama
di RS:
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 8) Tingkat perkembangan
Usia:
Karakteristik:
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7. Data laboratorium
Pemeriksaan laboratorium tanggal ......................................
Jenis Hasil Nilai Normal
Pemeriksaan
Hemoglobin
Leukosit
Eosinofil
Basofil
Neutrofil
Monosit
Hematokrit
Eritrosit
Trombosit
MCV
MCH
Limfosit
Kimia Klinik
SGOT
SGPT
HBSAG

8. Hasil pemeriksaan diagnostik yang lain

1.
2.
9. Terapi Medis
Tanggal Jenis terapi Rute Dosis Indikasi terapi
terapi

10. Persepsi klien terhadap penyakitnya:

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11. Kesan perawat terhadap klien:
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Pengkajian menurut teori Comfort Kolcaba
Klien saat ini membutuhkan pelayanan kesehatan sebagai suatu kebutuhan akan
kenyamanan akibat dari tindakan pasca pembedahan kista ovarium (kistektomi).
TIPE COMFORT Relief Ease Transcendence
Physical

Phsychospiritual

Environmental

Social
B. Analisa data
Data Etiologi Masalah
DS :

DO :

DS :

DO :
C. Diagnosa Keperawatan
1) .........................................................................................
2) .........................................................................................
3) .........................................................................................
D. INTERVENSI ASUHAN KEPERAWATAN
No Tanggal Diagnosa NOC NIC
keperawatan
E. IMPLEMENTASI ASUHAN KEPERAWATAN
Tanggal No Diagnosa Jam Implementasi
keperawatan
F. EVALUASI
Hari/tanggal/ No Diagnosa Evaluasi TTD
jam keperawatan
S:

O:

A:

P: