KEPERAWATAN MATERNITAS

PROGRAM PENDIDIKAN PROFESI NERS

UNIVERSITAS RESPATI YOGYAKARTA

PEDOMAN PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA

WANITA DENGAN PERMASALAHAN REPRODUKSI

Tanggal Pengkajian :………………………………..

Jam :………………………………..

BIODATA
Klien Penanggung Jawab
………………………………………….
Nama :……………………………
…………………………………………..
Agama :……………………………
…………………………………………..
Pendidikan : ………………………......
Pekerjaan : …………………………..
Status Pernikahan : …………………………..
Alamat : ……………………….….
……………………….…..
……………………………
Diagnosa Medis :……………………….……

STATUS KESEHATAN SAAT INI

1. Alasan kunjungan/keluhan utama :
………………………………………………………………….. ... ……….
………………………………………………………………….. ... ……….
……………………………………………………………….. ....... ……….
2. Faktor pencetus : ........................................................... ………..
3. Lamanya keluhan : ........................................................... ………..
4. Timbulnya keluhan :( ) Bertahap
( ) Mendadak
5. Faktor yang memperberat : ........................................................... ………..
6. Upaya yang dilakukan untuk mengatasinya :
Sendiri : ............................................................................ ………..
Oleh orang lain : ............................................................................ ………..
7. Diagnosa Medik : ............................................................................
........................................ Tanggal ..................................................
........................................ Tanggal ..................................................
........................................ Tanggal ..................................................
........................................ Tanggal ..................................................
RIWAYAT KELUARGA
Genogram :

RIWAYAT MASA LALU

1. Penyakit yang pernah dialami
a. Kanak-kanak : .....................................................................
b. Kecelakaan : .....................................................................
c. Pernah dirawat : .....................................................................
d. Operasi .......................... : ............................................................
2. Alergi ................................................................................................
Tipe ................................... Reaksi ...................................................
Tindakan ...........................................................................................
3. Imunisasi ...........................................................................................
Tipe ................................... Reaksi ...................................................
Tindakan ............................................................................................
4. Kebiasaan : merokok/kopi/obat/alkohol/lain-lain : ..........................
5. Obat-obatan : ..................................................................................
Lamanya : ..................................................................................

PEMERIKSAAN FISIK DAN KELUHAN FISIK YANG DIALAMI

Keadaan umum :
Kesadaran :
Vital Sign :
S :
N :
T :
P :
Kepala :
Bentuk ...................................................................................................
Keluhan yang berhubungan : pusing/sakit kepala/ .................................

Mata :
Ukuran pupil ........................ isokor ......................................................
Akomodasi ............................................................................................
Bentuk ...................................................................................................
Konjungtiva ...........................................................................................
Fungsi penglihatan : baik/kabur/tidak jelas ...........................................
Dua bentuk ............................................................................................
Tanda-tanda radang ...............................................................................
Pemeriksaan mata terakhir ....................................................................
Operasi ..................................................................................................
Kacamata ...............................................................................................
Lensa kontak .........................................................................................

Hidung :
Reaksi alergi ..........................................................................................
Cara mengatasinya ................................................................................
Pernah mengalami flu ...........................................................................
Bagaimana frekuensinya dalam setahun ...............................................
Sinus .................................... Perdarahan ..............................................

Mulut dan tenggorok :

Kesulitan/gangguan berbicara ...............................................................
Kesulitan menelan .................................................................................

Pernafasan :
Suara paru ..............................................................................................
Pola nafas ..............................................................................................
Batuk .....................................................................................................
Sputum ..................................................................................................
Nyeri ......................................................................................................
Kemampuan melakukan aktivitas .........................................................
Rontgen foto terakhir ................................... hasil ...............................

Sirkulasi :
Nadi perifer ...........................................................................................
Capillary refilling ..................................................................................
Distensi vena jugularis ..........................................................................
Suara jantung .........................................................................................
Suara jantung tambahan ........................................................................
Irama jantung (monitor) ........................................................................
Nyeri ......................................................................................................
Edema ....................................................................................................
Palpitasi .................................................................................................
Baal .......................................................................................................
Perubahan warna (kulit, kuku, bibir, dll) ...............................................
Clubbing ................................................................................................
Keadaan ekstremitas ..............................................................................
Syncope .................................................................................................

Nutrisi :
Berat badan .......................... Tinggi badan ...........................................
Status gizi ..............................................................................................
 Jenis diet ................................................................................................
Nafsu makan ..........................................................................................
Rasa mual ..............................................................................................
Muntah ..................................................................................................
Intake cairan ...........................................................................................

Eliminasi :
B.A.B
Pola rutin ...............................................................................................
Penggunaan pencahar ............................................................................
Colostomi/illeostomi .............................................................................
Konstipasi/obstipasi ..............................................................................
Diare ......................................................................................................
B.A.K
Pola rutin ...............................................................................................
Inkontinensia .........................................................................................
Infeksi ....................................................................................................
Hematuri ................................................................................................
Kateter ...................................................................................................
Urin output ............................................................................................

Reproduksi :
Reproduksi : Kehamilan G......P......A.......
No Gg. Proses Lama Tempat Masalah Masalah Keadaan
anak keha persali persali persalinan persalinan bayi anak saat ini
milan nan nan / penolong

Pemeriksaan payudara ....................... Keluhan payudara ...................... ……….

Pemeriksaan genetalia ....................... Keluhan genetalia ...................... ……….
Usia menarche ....................................................................................... ……….
Siklus menstruasi .............................. Karakteristik menstruasi ............ ……….
................................................................................................................
Menopause……………………Keluhan yang muncul selama ini .........
Masalah yang berhubungan dengan kesehatan reproduksi ....................
................................................................................................................
Sejak kapan ....................................... Sudah dilakukan apa ..................
Pembedahan ginekologi ........................................................................
Kapan .....................................................................................................
Pengaruh pembedahan terhadap kehidupan seksualitasnya ...................
................................................................................................................
Pemeriksaan papsmear terakhir .............................................................
 Hasil ......................................................................................................
Keputihan ..............................................................................................
Penggunaan kateter ...............................................................................

Neurosis :
Tingkat kesadaran ............................. GCS ...........................................
Disorientasi ...........................................................................................
Tingkah laku...........................................................................................
Riwayat epilepsi/kejang/parkinson ........................................................
Reflex .....................................................................................................
Kekuatan menggenggam ........................................................................

Muskuloskeletal :
Kekuatan otot ........................................................................................
Pergerakan ekstremitas ..........................................................................
Nyeri ......................................................................................................
Kekakuan ...............................................................................................
Pola latihan gerak ..................................................................................

Kulit :
Warna ....................................................................................................
Integritas ................................................................................................
Turgor ....................................................................................................

KESEHATAN LINGKUNGAN
Kebersihan : .......................................................................................
Bahaya : .......................................................................................
Polusi : .......................................................................................

PSIKOSOSIAL
1. Pola pikir dan persepsi
a. alat bantu yang digunakan :
( ) kacamata
( ) alat bantu
Kesulitan yang dialami :
( ) sering pusing
( ) menurunnya sensitifitas terhadap sakit
( ) menurunnya sensitifitas terhadap panas/dingin
( ) membaca/menulis

2. Persepsi diri
Hal yang sangat dipikirkan saat ini : ........................................
Harapan setelah menjalani perawatan : ........................................
Perubahan yang dirasa sakit : ........................................

3. Suasana hati : ..........................................................................

 Rentang perhatian : ..........................................................................
4. Hubungan/komunikasi
a. Bicara Bahasa utama :
( ) jelas
( ) relevan
( ) mampu mengekspresikan
( ) mampu mengerti orang lain, yaitu : ...................................
b. Tempat tinggal :
( ) sendiri
( ) bersama orang lain : yaitu .................................................
Kehidupan keluarga
- adat istiadat yang dianut : .....................................
- pembuatan keputusan dalam keluarga : .....................................
- pola komunikasi : .....................................
- Keuangan :
( ) memadai
( ) kurang
Kesulitan dalam keluarga
( ) hubungan dengan orang tua
( ) hubungan dengan sanak keluarga
( ) hubungan perkawinan

5. Kebiasaan seksual
a. Gangguan hubungan seksual disebabkan kondisi sebagai berikut :
( ) fertilitas ( ) menstruasi
( ) libido ( ) kehamilan
( ) ereksi ( ) alat kontrasepsi
b. Pemahaman terhadap fungsi seksual : ..........................................
.......................................................................................................
c. Masalah kebiasaan seksual yang dialami : ...................................

6. Pertahanan Koping
Pengambilan keputusan
( ) sendiri
( ) dibantu orang lain, sebutkan : ...........................................
Yang disukai tentang diri sendiri : ....................................................
Yang ingin diubah dari kehidupan : .................................................
Yang dilakukan jika stress
( ) pemecahan masalah
( ) makan
( ) tidur
( ) makan obat
( ) cari pertolongan
( ) lain-lain (misal : marah, diam , dll), sebutkan ...................
......................................................................................................
Apa yang dilakukan perawat agar anda nyaman dan aman : ........
 7. Sistem nilai – kepercayaan
Siapa atau apa sumber kekuatan : .....................................................
Apakah Tuhan, Agama, Kepercayaan penting untuk anda :
………………………………………………………………………………………
Kegiatan agama atau kepercayaan yang dilakukan (macam dan frekuensi), sebutkan
Kegiatan agama atau kepercayaan yang ingin dilakukan selama di Rumah Sakit, sebutkan

8. Tingkat perkembangan :
Usia : ............................................. Karakteristik : ..........................

DATA LABORATORIUM
Tanggal Jenis Hasil nilai Interpretasi
Pemeriksaan Pemeriksaan normal

PENGOBATAN
Tanggal Jenis terapi Rute terapi Dosis Indikasi terapi