Format Asuhan Gangguan Reproduksi

ASUHAN KEPERAWATAN PADA Ny..................

DENGAN.........................................
DI RUANG..........................
RS………………………..
TANGGAL..........

A. PENGKAJIAN
A. IDENTITAS PASIEN PENANGGUNG/ SUAMI
Nama : ...................... Nama : ...................
Umur : ...................... Umur : ……………
Pendidikan : ...................... Pendidikan : ……………
Pekerjaan : ...................... Pekerjaan : …................
Status perkawinan : ...................... Alamat : ...................
Agama : ......................
Suku : ......................
Alamat : ......................
No. CM : ......................
Tangal MRS : ......................
Tanggal Pengkajian : ......................
Sumber informasi : ......................

B. ALASAN DIRAWAT
1. Alasan MRS

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2. Keluhan saat dikaji

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C. RIWAYAT OBSTERTRI DAN GINOKOLOGI

a. Riwayat Menstruasi :
 Menarche : Umur .......... Siklus : teratur ( ) tidak ( )
 Banyaknya : .................... Lamanya : .....................................
 Keluhan : ....................
 HPHT : ....................
 b. Riwayat Pernikahan :
 Menikah : ....................kali Lama..................................tahun.

c. Riwayat kelahiran, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak
No Tahun Umur Penyulit Jenis Penolong Penyulit Lase Infeksi Pedarahan Jenis BB Pj
kehamilan rasi kelamin

d. Riwayat Keluarga Berencana :

 Akseptor KB : jenis ............... Lama : ..................
 Masalah : .......................
 Rencana KB : .......................

D. POLA FUNGSIONAL KESEHATAN

1. Pola Manajemen Kesehatan-Persepsi Kesehatan

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2. Pola Metabolik-Nutrisi

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3. Pola Eleminasi

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4. Pola Aktivitas-Latihan
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5. Pola Istirahat-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 Reproduktif-Seksualitas

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10. Pola Toleransi Terhadap Stres-Koping

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11. Pola Keyakinan-Nilai

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E. PEMERIKSAAN FISIK
Keadaan umum
- GCS : ......................................
- Tingkat kesadaran : ......................................
- Tanda-tanda fital : TD ............. N .............. RR .............. T ...............
- BB : ................... TB : ............... LILA : ........

Head to toe
Kepala Wajah
o Inspeksi : .............................................................
o Palpasi : .............................................................

Leher
o Inspeksi : .............................................................
o Palpasi : .............................................................

Dada
o Inspeksi : .................................................
o Palpasi : .................................................
o Perkusi : .................................................
o Auskultasi : …………..............................................

Abdomen
o Inspeksi :.............................................................
o Auskultasi : ............................................................
o Perkusi :.............................................................
o Palpasi : .............................................................

Genetalia
o Kebersihan : ......................................
o keputihan : .....................................

Perineum dan anus

o Perineum : .....................................
o Hemoroid : ......................................

Ekstremitas :
 Atas : ......................................
Oedema : ......................................
Varises : ......................................
CRT : ......................................

Bawah
Oedema : ......................................
Varises : ......................................
CRT : .......................................
Pemeriksaan Reflek : ............................

F.DATA PENUNJANG
 Pemeriksaan Laboratorium :

 Pemeriksaan radiologik :

G. DIAGNOSA MEDIS
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H. PENGOBATAN
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I. ANALISA DATA
DATA FOKUS ANALISIS MASALAH
Diagnosa keperawatan berdasarkan prioritas (SDKI) :

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II. RENCANA KEPERAWATAN

No Tgl/Jam No Rencana Keperawatan
Dx
Tujuan Intervensi Rasional
 III. IMPLEMENTASI
Tgl/Jam No. Implementasi Respon Paraf/
Dx Nama
 IV. EVALUASI

Tgl/Jam No Evaluasi Hasil Paraf

Dx
Denpasar, …………………….20…..
Mahasiswa
(………………………….)
NIM:

Clinical Teacher/CT

(……..………………)
NIP