YAYASAN MARANATHA NUSA TENGGARA TIMUR

SEKOLAH TINGGI ILMU KESEHATAN MARANATHA KUPANG

PROGRAM STUDI NERS
JL. KAMP. BAJAWA NASIPANAF BAUMATA BARAT – KAB. KUPANG

FORMAT PENGKAJIAN
GANGGUAN SISTEM REPRODUKSI

Nama Mahasiswa : ...........................................

NIM : ...........................................
Tempat Praktek : ...........................................
Tanggal Pengkajian : ...........................................

Identitas Klien
Nama :
Umur :
Jenis kelamin :
Alamat :
Status perkawinan :
Agama :
Pendidikan :
Pekerjaan :
Tanggal masuk RS :
Tanggal pengkajian :
Sumber informasi :
Keluarga yang dapat dihubungi :

Status Kesehatan Saat Ini

Alasan kunjungan /keluhan saat ini:
.............................................................................................................................................
Faktor pencetus :
..............................................................................................................................................
Lamanya keluhan:
....................................................................................................................................

Timbulnya keluhan:
..............................................................................................................................................
Faktor yang memperberat:
.....................................................................................................................................
Upaya yang dilakukan untuk mengatasi:
..............................................................................................................................................

Diagnosa medic : ..........................................................................................................

Riwayat Keluarga :
Genogram
Riwayat Kesehatan yang Lalu
 1. Penyakit yang pernah dialami
.................................................................................................................................
2. Alergi..............................................................................................................
3. Imunisasi...................................................................................................................
4. Kebiasaan merokok, kopi, obat, dan
alcohol............................................................................................................
5. Obat-obatan
.................................................................................................................................

Pengkajian Fisik

Kesadaran : ............................................................................................................
Tanda Vital :
TD :
S :
N :
RR :
BB/TB :

Kepala
Bentuk : .................................................................................................................
Mata : ....................................................................................................................
Hidung : .................................................................................................................
Mulut dan Tenggorok : ...........................................................................................
Pernafasan: .................................................................................................................................
Sirkulasi: .................................................................................................................................

Nutrisi: .................................................................................................................................

Eliminasi: .................................................................................................................................

Kesehatan Reproduksi : Kehamilan :

No. Gg. Proses Lama Tempat Masalah Masalah Masalah Keadaan

Anak Keha Persalinan Persalinan Persalinan Persalinan Nifas Dan bayi anak saat
milan Laktasi ini

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 : ..............................................................................................................
Upaya yang dilakukan :...............................................................................................
Pembedahan: ...............................................................................................................

Pemeriksaan papsmear terakhir ...................................................................................

Neurologi : .................................................................................................................

Muskuloskeletal/Integumen : ......................................................................................

Riwayat Lingkungan: .........................................................................................................

Aspek psikososial :

1. Pola pikir dan persepsi: ......................................................................................

2. Suasana hati : ...................................................................................................

3. Hubungan/komunikasi :....................................................................................

4. Kebiasaan Seksual :...........................................................................................

5. Pertahanan koping :.........................................................................................

6. Sistem Nilai dan kepercayaan :..........................................................................

7. Tingkat perkembangan :....................................................................................

Pemeriksaan Penunjang :
..............................................................................................................................................
Terapi Medis yang diberikan:
..............................................................................................................................................