LAMPIRAN 4:

PENGKAJIAN ASUHAN KEPERAWATAN

WANITA DENGAN PERMASALAHAN REPRODUKSI

Nama Mahasiswa ........................................................................................

Tempat praktek :.......................................................................................
Tanggal :.......................................................................................
I. Identitas diri klien
Nama : ............................................................................
Umur : ............................................................................
Jenis Kelamin : ............................................................................
Agama : ............................................................................
Pendidikan : ............................................................................
Pekerjaan : ............................................................................
Tanggal Masuk R S : ............................................................................
Sumber Informasi : ............................................................................
Keluarga terdekat yang dapat segera dihubungi (Orang tua, wali, suami, istri dll)
...............................................................................................................
Tanggal, jam pengkajian : ......................................................................

II. Status kesehatan saat ini

1. Alasan kunjungan/ keluhan utama
..........................................................................................................
..........................................................................................................
..........................................................................................................
2. Faktor pencetus : .............................................................
3. Lamanya keluhan : .............................................................
4. Timbulnya keluhan :( ) bertahap
( ) mendandak
5. Faktor yang memperberat : .............................................................
6. Upaya yang dilakukan untuk mengatasinya
Sendiri : .............................................................
Oleh orang lain : .............................................................
Diagnosa medik : .......................................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................
.............................................Tanggal.....................................................
III. Riwayat Penyakit Sekarang
..............................................................................................................
..............................................................................................................
..............................................................................................................
IV. Riwayat Keluarga
Genogram :

V. Riwayat Kesehatan yang lalu

1. Penyakit yang pernah dialami
...........................................................................................................................................................
.................................................
2. Alergi : ........................................................................
Tipe...................................Reaksi.....................................................
Tindakan...........................................................................................
3. Imunisasi : .........................................................................
Tipe...................................Reaksi.....................................................
Tindakan...........................................................................................
4. Kebiasaan : Merokok/kopi/obat/alkohol/lain-lain : .........................
5. Obat-obatan : .................................................................................
lamanya : .................................................................................

VI. Pemeriksaan Fisik dan Keluhan Fisik yang Alami

Keadaan umum
Kesadaran :
Vital Sign :
S :
N :
TD :
P :

Kepala
Bentuk....................................................................................................
Keluhan yang berhubungan : pusing/sakit kepala/................................

Mata
Ukuran pupil..........................................................................................
Ukuran akomodasi.................................................................................
Bentuk ...................................................................................................
Konjungtiva............................................................................................
Fungsi penglihatan : baik/kabur/tidak jelas...........................................
Dua bentuk............................................................................................
Tanda-tanda radang...............................................................................
Pemeriksaan mata terakhir....................................................................
Operasi ..................................................................................................
Kaca mata .............................................................................................
Lensa kontak .........................................................................................
Hidung
Reaksi alergi...........................................................................................
Cara mengatasinya.................................................................................
Pernah mengalami flu ...........................................................................
Bagaimana frekuensinya dalam setahun...............................................
Sinus..............................perdarahan .....................................................

Mulut dan tenggorok

Gigi geligi................................................................................................
Kesulitan/ gangguan berbicara..............................................................
Kesulitan menelan.................................................................................
Pemeriksaan gigi terakhir......................................................................
Pernafasan
Suara paru..............................................................................................
Pola nafas...............................................................................................
Batuk .....................................................................................................
Sputum..................................................................................................
Nyeri .....................................................................................................
Kemampuan melakukan aktivitas .........................................................
Batuk darah ...........................................................................................
Rontgen foto terakhir.................................hasil ...................................
Sirkulasi
Nadi perifer............................................................................................
Capilary refiling .....................................................................................
Distensi vena jugularis...........................................................................
Suara jantung ........................................................................................
Suara jantung tambahan .......................................................................
Irama jantung (monitor) .......................................................................
Nyeri .....................................................................................................
Edema....................................................................................................
Palpitasi .................................................................................................
Baal .......................................................................................................
Perubahan warna (kulit, kuku, bibir dll) ................................................
Clubbing ................................................................................................
Keadaan ekstremtitas ...........................................................................
Syncope .................................................................................................

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

Eliminisi
BAB
Pola rutin ...............................................................................................
Penggunaan pencahar...........................................................................
Colostomi/ ileostomi..............................................................................
Konstipasi/ obstipasi..............................................................................
Diare .....................................................................................................
BAK
Pola rutin ...............................................................................................
Inkontinensia.........................................................................................
Infeksi....................................................................................................
Hematuri................................................................................................
Kateter...................................................................................................
Urin output............................................................................................
Reproduksi
Reproduksi : Kehamilan G …. P…. A….
Gg. Proses Lama Tempat Masalah Keadaan
No. Masalah
KehamilPersalin Persalin Persalinan/ Persalina Anak
Anak bayi
an an an penolong n Saat ini

Pemeriksaan payudara..................keluhan payudara...........................

Pemeriksaan genetalia...................keluhan genetalia...........................
Usia menarche.......................................................................................
Siklus menstruasi.................karakteristik menstruasi...........................
...............................................................................................................
Sejak kapan terdiagnosa……………………………………………………………………..
Sudah dilakukan apa…………………………………………………………………………..
Pengaruh perbedaan terhadap kehidupan seksualitas..........................
...............................................................................................................
Pemeriksaan papsmear terakhir............................................................
Hasil.......................................................................................................
Keputihan ..............................................................................................

Neurologis
Tingkat kesadaran................................................GCS...........................
Disorientasi............................................................................................
Tingkah laku...........................................................................................
Riwayat epilepsy/kejang/Parkinson.......................................................
Reflek.....................................................................................................
Kekuatan menggenggam.......................................................................

Musculoskeletal
Kekuatan otot........................................................................................
Pergerakan ekstremitas.........................................................................
Nyeri......................................................................................................
Kekakuan...............................................................................................
Pola latihan gerak..................................................................................

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

VII. Kesehatan Lingkungan

Kebersihan : .........................................................................
Bahaya : .........................................................................
Polusi : .........................................................................

VIII. Psikososial
1. Pola pikir dan perspsi
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. Perspsi 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 lain
( ) 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 kehiduapan...................................................
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 apa sumber kekuatan :............................................................
Apakah Tuhan, Agama, kepercayaan itu penting untuk anda:.........
..........................................................................................................
Kegiatan agama atau kepercayaan yang ingin dilakukan selama di rumah sakit, sebutkan :
..........................................................................................................
..........................................................................................................
8. Tingkat perkembangan
Usia............................... Karakteristik..........................
Obat-obatan yang digunakan :
Hari / Waktu
No Nama Obat Dosis Instruksi
Tanggal Pemberian

Hasil Pemeriksaan penunjang :

Tanggal
No Jenis Pemeriksaan Hasil
Periksa
ANALISA DATA
DATA PROBLEM ETIOLOGI
DS :

DO :

DS :

DO :

DS :

DO :

DIAGNOSA KEPERAWATAN PRIORITAS

1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
4. ...............................................................................................................
5. ...............................................................................................................
INTERVENSI KEPERAWATAN
NO.
NOC NIC
Dx
IMPLEMENTASI KEPERAWATAN
Tgl /
NO.Dx IMPLEMENTASI RESPON TTD
Jam
EVALUASI KEPERAWATAN
NO.Dx Tgl / Jam EVALUASI TTD
S:

O:

A:

P: