Pengkajian Asuhan Keperawatan Antenatal Care Pada ........

G........ P.......A.........dengan

PENGKAJIAN PRENATAL
Nama Mahasiswa :
Nim :

DATA UMUM KLIEN

Nama : Tanggal Pengkajian :
No.Reg : Ruangan :
Rumah Sakit : Tanggal Masuk :
Diagnosa Medis :

I. Data umumklien
1. Inisial klien : Inisial Suami :
2. Usia : Usia :
3. Status Perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan Terakhir : Pendidikan Terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

Riwayat Kehamilan dan Persalinan yang lalu

Jenis Jenis Keadaan Bayi Masalah
No Tahun Persalinan Penolong Kelamin waktu lahir Kehamilan

Pengalaman menyusui ekslusif: Berapa lama:

Riwayat Ginekologi
1. Masalah Ginekologi :
2. Riwayat KB :

Riwayat Kehamilan saat ini:

HPHT : Taksiran partus:
Letak/presentasi Usia
TD BB/TD DJJ Keluhan Data Lain
janin Gestasi

BB sebelum hamil : TD sebelum hamil

DATA UMUM KESEHATAN SAAT INI

Status obstetrik: G.........P........A.........H........ minggu
Keadaan umum: Kesadaran:.....................
BB/TB : Kg/cm
1. Tanda Vital
Tekanan Darah :...............mmHg Nadi :.............x/mnt
Suhu Badan :............ C
o
Pernapasan :.............. x/mnt

2. Kepala Leher
Kepala
...................................................................................................................................
...................................................................................................................................
Mata
...................................................................................................................................
...................................................................................................................................
Hidung
...................................................................................................................................
...................................................................................................................................
Mulut
...................................................................................................................................
...................................................................................................................................
Telinga
...................................................................................................................................
...................................................................................................................................
Leher
...................................................................................................................................
...................................................................................................................................
Masalah Khusus :................................................................................................

3. Dada
 Jantung :................................................................................................
.................................................................................................
.................................................................................................
Paru :................................................................................................
.................................................................................................
.................................................................................................
Payudara :................................................................................................
.................................................................................................
.................................................................................................
Puting susu :................................................................................................
.................................................................................................
.................................................................................................
Pengeluaran ASI :................................................................................................
.................................................................................................
.................................................................................................
MasalahKhusus :................................................................................................

4. Abdomen
Uterus
TFU:.................cm kontraksi : ya/tidak
Leopold I : Kepala/bokong/kosong
LeopolII : Kanan : punggung/bagian kecil/bokong/kepala
Kiri : punggung/bagian kecil/bokong/kepala
Leopold III : Kepala/bokong/kosong
Leopold IV : Bagian masuk PAP
Pigmentasi
Linea Nigra : .......................................................................................
Striae :........................................................................................
Fungsi pencernaan : .......................................................................................
Ada/tidak luka operasi : .......................................................................................
Masalah Khusus : .......................................................................................

5. Perineum dan Genital

Vagina : varises; ya/tidak
Kebersihan :.............................................................................................
Keputihan :..............................................................................................
Jenis/warna :.................. konsistensi:.................. Bau:.........................
Hemorrhoid :
Derajat :....................... Lokasi:..........................................................
Berapalama :.......................Nyeri :ya/tidak
Masalah khusus :...................................................................................................

6. Ekstremitas
 Ekstremitas Atas
Edema : ya/tidak Varises:ya/tidak
Ekstremitas Bawah
Edema : ya/tidak Varises:ya/tidak
Refleks patela : +/- jika ada :
Masalah khusus :....................................................................................................

7. Eliminasi
Urin : kebiasaanBAK......................................................................................
Fekal : kebiasaanBAB......................................................................................
Masalah khusus :.....................................................................................................

8. Mobilisasi dan Latihan

Tingkat Mobilisasi :..............................................................................................
Latihan/senam :..............................................................................................

MasalahKhusus :.....................................................................................................

9. Nutrisi dan Cairan

Asupan nutrisi (frekuensi dan porsi makan jenis makanan)
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Nafsu Makan : baik/kurang/tidak ada
Asupan cairan:..........................................................................................................
...........................................................................................................

Masalah khusus :..................................................................................................

10. Seksualitas
Frekuensi :.................................................................................................................
...................................................................................................................................
Posisi :................................................................................................................
...................................................................................................................................

Masalah khusus :.....................................................................................................

11. Dukungan suami/keluarga terhadap kehamilan:

...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

Keadaan Mental
 Adaptasi
psikologis :................................................................................................................
...................................................................................................................................
...................................................................................................................................
.................
Penerimaan terhadap kehamilan:
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Masalah khusus:......................................................................................................

12. Pola hidup yang meningkatkan resiko kehamilan :

...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

13. PersiapanPersalinan
 SenamHamil
 Rencana tempatmelahirkan
 Kesiapan biaya persalinan
 Perlengkapan kebutuhan bayi dan ibu
 Kesiapan mental ibu dankeluarga
 Pengetahuan tentang tanda-tanda melahirkan, cara menangani nyeri, proses
persalinan.
 Perawatan payudara

14. Obat-obatan yang dikonsumsi saat ini :

15. Hasil Pemeriksaan penunjang :

 Rangkuman Hasil Pengkajian

16. Perencanaan Kunjungan Rumah :

 Pengkajian Asuhan Keperawatan Intranatal Care Pada ........
G........ P.......A.........dengan

I. PENGKAJIAN INTRANATAL
Nama Mahasiswa :
Nim :

II. DATA UMUM KLIEN

Nama : Tanggal pengkajian :
No.Reg : Ruangan :
Rumah Sakit : Tanggal Masuk :
Diagnosa Medis ....................................

Data umumklien
1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

III. DATA UMUMKESEHATAN

1. TB/BB: ...............cm/ …...........kg
2. BB sebelum hamil.............kg
3. Masalah Kesehatan khusus:................................................................................
.............................................................................................................................
4. Obat – obatan :....................................................................................................
5. Alergi (obat/makanan/bahan tertentu):...............................................................
.............................................................................................................................
6. Diet Khusus:........................................................................................................
7. Alat bantu yang digunakan : (gigi tiruan/kacamata/lensa kontak/alat dengar)*
Lain – lain :.........................................................................................................
..........................................................................................................
8. Frekuensi BAB/BAK:.........................................................................................
 9. Masalah BAB/BAK:...........................................................................................
.............................................................................................................................
10. Kebiasaan waktu tidur:.......................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

IV. DATA UMUM KEBIDANAN

1. Kehamilan sekarang direncanakan (ya/tidak)*

2. Status Obstetri :G........P........A.........H.........

HPHT :.................................................Taksiran partus :....................................
Jenis Umur Cara Penolong Penyulit BB Keadaan
No Umur
Kelamin kehamilan Lahir Persalinan persalinan Lahir saat ini

3. Jumlah anak di rumah:............................................................................................

4. Mengikuti kelas prenatal (ya/tidak) :.......................................................................

5. Jumlah kunjungan ANC pada kehamilan ini :.........................................................
.................................................................................................................................
6. Masalah kehamilan yang lalu :................................................................................
.................................................................................................................................
7. Masalah kehamilan sekarang:.................................................................................
.................................................................................................................................
8. RencanaKB:.............................................................................................................
9. Makanan bayi sebelumnya : ASI? PASI? lainnya*
10. Pelajaran yang diinginkan saat ini : (lingkari)
Relaksasi/pernafasan/manfaat ASI/cara memberi minum botol/senam nifas/
metoode KB/perawatan perineum/perawatan payudara/lain-lain
11. Jelaskan :................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

12. Setelah bayi lahir, siapa yang diharapkan membantu:

 .................................................................................................................................
13. Masalah dalam persalinan yang lalu:
.................................................................................................................................

V. RIWAYAT PERSALINANSEKARANG
1. Mulai persalinan (kontraksi) tanggal/jam:..............................................................
2. Pengeluaran pervaginam (tanggal/jam):..................................................................
3. Keadaan kontraksi (frekuensi dalam 10 menit, lamanya, kekuatannya) :
.................................................................................................................................
.
.................................................................................................................................
.

4. Denyut jantungjanin : Frekuensi :...........................................................................

Kualitas :...........................................................................
Irama :...........................................................................
5. Pemeriksaan fisik :
Kenaikan BBselama hamil….........kg
TTV : TD.......................mmHg, N.............x/mnt,
RR...................x/mnt, SB..............0c
Kepala dan leher :.......................(normal/tidak)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Jantung :................................................................................................
.................................................................................................................................
Paru :................................................................................................
.................................................................................................................................
Payudara :...............................................................................................
.................................................................................................................................
.................................................................................................................................
Abdomen : (secara umum dan pemeriksaan
obstetrik) :................................................................................................................
.................................................................................................................................
................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
 6. Ekstremitas : edema/tidak
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Refleks :............................................................................................................
7. Pemeriksaan dalam pertama : (jam) .................oleh:............................................
Hasil :...............................................................................................................
8. Ketuban : (utuh/pecah)
jika sudah pecah : tgl/jam:.......................................................................................
Warna
9. Laboratorium...........................................................................................................

VI. DATA PSIKOSOSIAL

1. Penghasilan keluarga setiap bulan :....................................................................
.............................................................................................................................
2. Perasaan klien terhadap kehamilan sekarang:.....................................................
.............................................................................................................................
3. Perasaan suami terhadap kehamilan sekarang :..................................................
.............................................................................................................................
4. Jelaskan respon sibling terhadap kehamilan sekarang :......................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

VII. LAPORAN PERSALINAN

a. Pengkajian awal
1. Tanggal : ............................................. Jam:.................
2. TTV : TD.....................mmHg, N : .............x/mnt,
SB :...........oC, PP.............x/mnt
3. Pemeriksaan palpasi abdomen
Leopold I :.......................................................................................................
.......................................................................................................
Leopold II :......................................................................................................
.......................................................................................................
Leopold III :......................................................................................................
.......................................................................................................
Leopold IV :.......................................................................................................
.......................................................................................................

4. Hasil pemeriksaan dalam :..................................................................................

 5. Pemeriksaan perineum :......................................................................................
6. Dilakukan klisma (ya/tidak) :..............................................................................
7. Pengeluaran pervaginam :...................................................................................
8. Perdarahan pervaginam: tidak/ya, jumlah….....ml
9. Kontraksi uterus (frekuensi, lamanya, kekuatan):
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
10. DJJ :(frekuensi/kualitas).....................................................................................
.............................................................................................................................
11. Status janin : (hidup/tidak,jumlah,presentasi) : ..................................................
.............................................................................................................................

b. Kala Persalinan
1. KalaI
I. Mulai persalinan : (tanggal/jam)....................................................................
II. Tanda dan gejala : ..........................................................................................
........................................................................................................................
III. Lama Kala I : (jam/menit/tidak).....................................................................
........................................................................................................................
IV. Keadaan psikososial : ....................................................................................
........................................................................................................................
........................................................................................................................
V. Kebutuhan khusus klien :...............................................................................
........................................................................................................................
VI. Tindakan :.......................................................................................................
........................................................................................................................
VII. Pengobatan : ..................................................................................................
VIII. Observasi kemajuan persalinan :
Tanggal/jam Kontraksi uterus DJJ Keterangan

2. Kala II
 a. Kala II dimulai : (Tgl/jam):............................................................................
b. TTV : TD................mmHg. N .............x/mnt,
SB....................oC, P...............x/mnt
c. Lama kala II :(jam/menit/detik).....................................................................
d. Keadaan psikososial :.....................................................................................
........................................................................................................................
e. Kebutuhan khusus klien:................................................................................
........................................................................................................................
........................................................................................................................
f. Tindakan :.......................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
................
g. Perineum (utuh/episiotomi/ruptur)*, jika ruptur, tingkat
ruptur :............................................................................................................
........................................................................................................................
........................................................................................................................
...........
h. Bonding ibu dan bayi (inisiasi menyusu
dini): ...............................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
.........
i. TTV bayi : TD.............mmHg, N................x/mnt,
SB...................oC, P.................x/mnt
j. Pengobatan : ..................................................................................................
........................................................................................................................
......................

Catatan kelahiran:
- Bayi lahir jam :...............................................................................................
- Cara Persalinan :……………………………….............................................
- Jenis Kelamin : ..............................................................................................
- Nilai APGAR menit I.................... menit V........................
- BB..................gram /PB..............cm /Lingkar Kepala................cm
 - Karakteristik khusus bayi :.............................................................................
- Kaput suksadaneum/cephal hematoma :........................................................
- Anus : berlubang/tertutup*
- Perawatan tali
pusat : .............................................................................................................
........................................................................................................................
...........
- Perawatan mata :............................................................................................

3. Kala III
a. Mulai jam : .........................
b. TTV : TD.................mmHg, N.................x/mnt,
SB.....................oC, P..................x/mnt
c. Tanda dan
gejala : ............................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
............
d. Plasenta lahir jam:..........................................................................................
e. Cara lahir plasenta:
........................................................................................................................
........................................................................................................................
........................................................................................................................
f. Karakteristik plasenta:
........................................................................................................................
g. Diameter................cm
h. Ketebalan...............cm
i. Panjang tali pusat : ......................cm
j. Jumlah pembuluh darah:...........................arteri...........................vena
k. Insersio tali pusat :..........................................................................................
l. Kelainan :.......................................................................................................
m. Pengeluaran darah pervaginam…....................ml
n. Karakteristik perdarahan:...............................................................................
o. Keadaan psikososial :.....................................................................................
p. Kebutuhan khusus:.........................................................................................
q. Tindakan:........................................................................................................
........................................................................................................................
r. Pengobatan :...................................................................................................
........................................................................................................................
........................................................................................................................
....................
4. Kala IV
a. Mulai jam : .....................
b. TTV : TD...................mmHg, N : ............x/mnt,
SB : .............oC, P :..............x/mnt
c. Kontraksi uterus : ..........................................................................................
d. Pengeluaran darah pervaginam................ml
e. Karakteristik : ................................................................................................
f. Tindakan : ......................................................................................................
........................................................................................................................
........................................................................................................................
..................
 Pengkajian Asuhan Keperawatan Bayi Baru Lahir Pada By. Ny. .....
Di ......................

I. FORMAT PENGKAJIAN BAYI BARU LAHIR

Nama By. :
Tempat Tgl. Lahir :
Umur :
Jenis Kelamin :
Kondisi Umum :
TTV : TD / mmHg N x/menit
SB 0c R x/menit

Riwayat kelahiran
- BB :
- Panjangbadan :
- Suhu :
- Lingkar Kepala :
- Lingkar dada :
- Masalah dalam proses kelahiran
:.......................................................................................................................................................
........................................................................................................................................................
- Lanugo :
- Vernix kaseosa :
- Mekonium :
- Warna tubuh :
- APGAR Score Menit I :
Menit V :
- Usia gestasi :

Pemeriksaan Reflek
- Reflek moro :
........................................................................................................................................................
........................................................................................................................................................
- Reflek menggegam : ......................................................................................................................
- Reflek mengisap :...........................................................................................................................
- Reflek tonik neck :.........................................................................................................................
- Tonus otot/aktivitas : .....................................................................................................................
- Kekuatan menangis : .....................................................................................................................

Pemeriksaan Fisik
a. Kepala
- Bentuk kepala :
- Ubun-ubun :
 - Mata :
- Telinga :

- Hidung :
- Mulut : reflek menelan dan menghisap....................labioskisis ( )
Palatoskisis ( ) Sianosis ( )

b. Punggung
- Keadaan punggung : Lecet ( ) Lordosis ( ) Skoliosis ( ) kifosis ( )
- Fleksibiltas tulang punggung :

c. Thorak
- Bentuk dada :
- Jenis pernapasan :
- Frekuensi napas :

d. Abdomen
- Bentuk abdomen :
- Bising usus :

e. Ekstremitas
- Jari kaki :
- Jari tangan :
- Pergerakan kaki :
- Pergerakan tangan :
- Garis telapak kaki :
- Warna ektremitas :
- Posisi ekstremitas :

f. Alatreproduksi
- Laki-laki (penurunan testis):
- Perempuan (labia minora, mayora, keluaran):
..................................................................................................................
g. Fungsieliminasi
- Fungsi miksi : frekuensi BAK.........,warna...............................................................................
- Anus :

Diagnosa Medis

Pola Fungsi Kesehatan Bayi

5. Nutrisi dan metabolisme :
6. Istirahat dan tidur :
7. Aktifitas dan latihan :
8. Lainnya :
Obat –obatan yang diberikan :
…………………………………………………………………………………
…………………………………………………………………………………..
............................................................................................................................

Pemeriksaan Lab :

Kesimpulan :
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
 Pengkajian Asuhan Keperawatan Postnatal Care Pada Ny. ......
Dengan Persalinan........................ Di...................................

PENGKAJIAN POST PARTUM

Nama Mahasiswa :
Nim :

DATA UMUM KLIEN

Nama : Tanggal pengkajian :
No.Reg : Ruangan :
Rumah Sakit : Tanggal Masuk :
DiagnosaMedis :

I. Data umum klien

1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

Riwayat Kehamilan dan Persalinan Yang Lalu

BB Keadaan
Tipe Jenis Penyulit Masalah
No. Tahun Penolong bayi waktu
Persalinan Kelamin persalinan Lahir kehamilan
lahir

Pengalaman menyusui ekslusif: ya/tidak

berapa lama:
II. Riwayat Kehamilan saat ini
1. Berapa kali periksa kehamilan..........................................................................
2. Masalah kehamilan............................................................................................
...........................................................................................................................

III. Riwayat Persalinan

1. Jenis persalinan : spontan (letkep/letsu)/Tindakan (EV, EF)
SC...........................tgl/jam:...................
2. Jenis kelamin bayi : L/P,
BB.....................gram / PB........................cm
3. Pengeluaran darah pervaginam….............. cc
4. Masalah dalam persalinan ..............................................................................

IV. Riwayat Ginekologi

1. Masalah ginekologi........................................................................................
2. Riwayat KB....................................................................................................

DATA UMUM KESEHATAN SAAT INI

Keadaan umum :
Kesadaran :
BB : gram/kg
TB : cm

I. Tanda vital
Tekanan Darah :........./..........mmHg; Nadi:...........x/mnt,
Suhu Badan :..............oC ,Pernapasan.............x/mnt

II. Kapala Leher

Kepala :..............................................................................................
...............................................................................................
Mata :..............................................................................................
...............................................................................................
Hidung :..............................................................................................
...............................................................................................
Mulut :..............................................................................................
...............................................................................................
Telinga :..............................................................................................
...............................................................................................
Leher :..............................................................................................
...............................................................................................
Masalah khusus :...............................................................................................
III. Dada
Jantung :...............................................................................................
.............................................................................................................................
............................
Paru :...............................................................................................
.............................................................................................................................
............................
Payudara :................................................................................................
.............................................................................................................................
...........................
Puting susu
:............................................................................................................................
............................................................................................................................
Pengeluaran ASI
:...........................................................................................................................
Masalah khusus :.................................................................................................

IV. Abdomen
Involusi Uterus
Fundus Uteri :..................... kontraksi :.......................
posisi:................................
Kandung kemih
Diastaksis rektus abdominis..................... x.................cm
Fungsi pencernaan :
Masalah khusus :..................................................................................

V. Perineum dan Genital

Vagina :
integritas kulit.....................................................................................................
edema..................................................................................................................
memar.................................................................................................................
hematom..............................................................................................................
Perineum : utuh/episiotomi/rupture
.............................................................................................................................
.............................................................................................................................

Tanda REEDA
R : Kemerahan :ya/tidak
E: Edema :ya/tidak
E: Ekimosis :ya/tidak
D : Dischargeserum :/pus/darah/tidak ada
A: Approximate : baik/tidak
 Kebersihan :...................................................................................................
Lokia
:..........................................................................................................
Jumlah :................................. Jenis/warna :...................................................
Konsistensi :........................................Bau :..................................................
Hemorrhoid :..................................................................................................
Derajat : .......................................... lokasi :..................................................
Berapa lama :….................................Nyeri :ya/tidak
Masalah khusus :............................................................................................

VI. Ekstremitas
Ekstremitas atas
Edema : ya/tidak Varises : ya/tidak
Ekstremitas Bawah
Edema : ya/tidak Varises : ya/tidak Homan : +/-
Masalah khusus :.................................................................................................

VII. Eliminasi
Urin : kebiasaan BAK............................................................................
BAKsaat ini.: nyeri/tidak....................................................................................
Fekal : kebiasaan BAB.............................................................................
BAB saatini konstipasi/tidak...............................................................................
Masalah khusus :.................................................................................................

VIII. Istirahat dan Kenyamanan

Pola tidur :
- Kebiasaan tidur, .............................................................................................
- lama........................jam,
- frekuensi..........................................................................................................
Pola tidur saat ini....................................................................................
Keluhan ketidaknyamanan : ya/tidak, Lokasi..................................................
Sifat........................................intensitas..................................................

IX. Mobilisasi dan Latihan

Tingkat mobilisasi :........................................................................................
........................................................................................................................
........................................................................................................................
Latihan/senam :.......................................................................................
........................................................................................................................
Masalah khusus :.......................................................................................
X. Nutrisi dan Cairan
Asupan nutrisi:
...........................................................................................................................
..........................................................................................................................
nafsu makan : baik/kurang/tidakada
...........................................................................................................................
...........................................................................................................................
Asupan cairan : cukup/kurang
...........................................................................................................................
...........................................................................................................................
Masalah khusus :.............................................

XI. Keadaan Mental

Adaptasi
psikologis :.................................................................................................................
....................................................................................................................................
.................
Penerimaan terhadap
bayi :...........................................................................................................................
....................................................................................................................................
.......
Masalah khusus :........................................................................................................

XII. Kemampuan menyusui

:..........................................................................................................................
...........................................................................................................................
Obat-obatan yang dikonsumsi saat ini :
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................

XIII. Hasil pemeriksaan penunjang :

RANGKUMAN HASIL PENGKAJIAN
Masalah :

Perencanaan Pulang :
Pengkajian Asuhan Keperawatan Keluarga Berencana Di……………………….

PENGKAJIAN KELUARGA BERENCANA

Nama Mahasiswa :
Nim :
Ruangan/RS :
Tanggal Masuk RumahSakit :

I. Data umum klien:

1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :

II.Data umum kesehatan saatini

1. TB :...............cm/ BB:………….kg
2. Keadaan
umum :................................................................................................................
.............................................................................................................................
...........
3. TTV : TD:....../......mmHg, N : ........x/mnt,
P :...........x/mnt, SB :……..oC
4. Kepala dan rambut :
a. Bentuk kepala
:...............................................................................................................
b. Keadaan
rambut :...................................................................................................
............
c. Kebersihan rambut
.................................................................................................................
5. Wajah/
muka :..................................................................................................................
.............................................................................................................................
.........
6. Mata :
a. Konjungtiva :..........................................................................................
b. Sclera :....................................................................................................
c. Gangguan penglihatan :..........................................................................
 7. Hidung :..............................................................................................................
.............................................................................................................................
8. Mulut:..................................................................................................................
.............................................................................................................................
9. Telinga:...............................................................................................................
.............................................................................................................................
10. Leher :.................................................................................................................
11. Dada :..................................................................................................................
............................................................................................................................
payudara :............................................................................................................
.............................................................................................................................
12. Abdomen :...........................................................................................................
.............................................................................................................................
13. Genitalia :............................................................................................................
.............................................................................................................................
14. Tungkai bawah :..................................................................................................
.............................................................................................................................
III. Data umumkebidanan
Status obstetrik : P.................... A .....................
Jumlah anak di rumah :

Jenis Cara
No Umur BB Lahir Keadaan Sekarang
Kelamin Persalinan

Alasan datang ke
klinik : .....................................................................................................................
.................................................................................................................................
............
Lama perkawinan : .................................................................................................
Masalah untuk hamil :.............................................................................................
Masalah selama kehamilan :...................................................................................
Masalah setelah melahirkan :.................................................................................
 Riwayat penggunaaan metode kontrasepsi (hormonal/non hormonal) :
Jenis Tahun s/d Masalah Alasan Penghentian
No Kontrasepsi Tahun Pemakaian Pemakaian

Cara KB yang diminati saat ini : ..................................................................

Riwayat sosial : ............................................................................................

Persetujuan/sikap suami terhadap Metode kontrasepsi yang dipilih :

.................................................................................................................................
.
.................................................................................................................................
.

Pengetahuan tentang berbagi metode kontrasepsi (pengertian,

keuntungan, efek samping, kontra indikasi) :
.................................................................................................................................
.
.................................................................................................................................
.
 Pengkajian Asuhan Keperawatan Gangguan Sistem Reproduksi
Pada Ny.........................Dengan.......................Di.......................

PENGKAJIAN GANGGUAN SISTEM REPRODUKSI (GSR)

Nama Mahasiswa :
NIM :

DATA UMUM KLIEN

Nama : Tanggal pengkajian :
No.Reg : Ruangan :
Rumah Sakit : Tanggal Masuk :
Diagnosa Medis :

I. Data umumklien
1. Inisial klien : Inisial suami :
2. Usia : Usia :
3. Status perkawinan : Suku :
4. Pekerjaan : Pekerjaan :
5. Pendidikan terakhir : Pendidikan terakhir :
6. Suku : Agama :
7. Agama :
8. Alamat :
9.
II. Masalah Utama
1. Keluhan
utama :.................................................................................................................
.............................................................................................................................
.............................................................................................................................
..........
2. Mulai
timbulnya :..........................................................................................................
.............................................................................................................................
................
3. Sifat
keluhan :..............................................................................................................
.............................................................................................................................
............
4. Lokasi
keluhan :..............................................................................................................
.............................................................................................................................
 ............
5. Faktor
pencetus :.............................................................................................................
.............................................................................................................................
..............

6. Keluhan
lain :.....................................................................................................................
......
7. Pengaruh keluhan terhadap aktivitas/fungsi tubuh:
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
8. Usaha klien untuk
mengatasinya :.....................................................................................................
.............................................................................................................................
.............................................................................................................................
......................

III.Pengkajian Fisik
1. Seksualitas
Subyektif:
a. Usia menarche :..............tahun
b. Siklus haid :..............hari
c. Durasi haid :...............hari

Dismenorea Polimenorea Oligomenorea

MenometroragieAmenorea
2. Rabas pervagina : Warna :....................................
Jumlah :...................................
Berapa lama :...................................
3. Metode kontrasepsi
terakhir : .............................................................................................................
................
4. Status obstetri : P................ A :.................
5. Riwayat persalinan :
Aterm : ...................................................................................................
prematur :....................................................................................................
Multiple : ...................................................................................................
6. Riwayat persalinan terakhir :
Tahun : ........................................................................................................
tempat :........................................................................................................
 Lama gestasi:...............................................................................................
lama persalinan:..................
Jenis persalinan :......................
Berat badan bayi:.....................
Komplikasi maternal/bayi : ........................................
Obyektif :
a. PAP smear terakhir (tgl dan hasil) :..........................................
b. Tes serologi (tgl dan hasil) :......................................................
7. Makanan dan cairan
Subyektif :
a. Masukan oral 4 jam terakhir : ...............................................
Mual/muntah
Hilangnafsu makan
Masalah mengunyah
b. Pola makan:
c. Frekuensi...........x/hari
d. Konsumsicairan............/hari
Obyektif :
a. BB...............kg
b. TB...............cm
c. Turgor kulit :....................................................
d. Membran mukosa mulut :................................
e. Kebutuhan cairan :...........................................
f. Pemeriksaan Hb. Ht (tgl dan hasil):.......................................................
8. Eliminasi
Subyektif :
a. Frekuensi dafekasi :.............................................................
b. Penggunaan laksatif :...........................................................
c. Waktu defekasi terakhir :.....................................................
d. Frekuensi berkemih :............................................................
e. Karakter urine :.....................................................................
f. Nyeri/rasa terbakar/kesulitan berkemih :...............................
g. Riwayat penyakit ginjal:.......................................................
h. Penyakit kandung kemih:......................................................
i. Penggunaan diuretik:.............................................................
Obyektif :
a. Pemasangan kateter:.........................................
b. Bising usus :...................................
c. Karakter urine :........................................................
d. Konsistensi feces :......................................................
e. Warna feces :..............................................................
f. Hemorrhoid :..............................................................
g. Palpasi kandung kemih (teraba/tidak
teraba) :.........................................

9. Hygiene
Subyektif :
a. Kebersihan rambut (frekuensi ):............................................
b. Kebersihan badan:..................................................................
c. Kebersihan gigi/mulut :.........................................................
d. Kebersihan kuku tangan dan kaki :........................................
Obyektif :
e. Cara berpakaian :....................................................................
f. Kondisi kulit kepala :..............................................................

10. Sirkulasi
Subyektif :
a. Riwayat penyakit jantung :..................................................
b. Riwayat demam reumatik:...................................................
c. Obyektif :
d. Tekanan darah :............................
e. Nadi :.............................
f. Distensi vena jugularis (ada/tidak ada) :................................
g. Bunyi jantung :.......................................................................
h. Frekuensi :........................................................................
i. Irama (teratur/tidak teratur) :............................................
j. Kualitas (kuat/lemah/Rub/Murmur) ; ...............................
 Ekstremitas :
k. Suhu (hangat/akral dingin) :.............................................
CRT :................................................................................
Varises (ada/tidak ada) : CRT :........................................

11. Nyeri/ketidaknyamanan
Subyektif :
a. Lokasi :..........................................................
b. Intensitas (skala 0 -10) :................................
c. Frekuensi :.....................................................
d. Durasi :..........................................................
e. Faktor pencetus :...........................................
f. Cara mengatasi :........................................................................
g. Faktor yang berhubungan :........................................................
Obyektif :
a. Wajah meringis Melindungi area yang sakit Fokus menyempit

12. Pernapasan
Subyektif :
Dispnea Batuk/sputum Riwayat Bronkitis
Asma Tuberkulosis Emfisema
Pneumonia berulang Perokok, lamanya.....................tahun
Penggunaan alat bantupernapasan(02)………L/mnt
Obyektif :
a. Frekuensi.................x/mnt
b. Irama Eupnoe Tachipnoe Bradipnoe
Apnoe Hiperventilasi Cheynestokes Kusmaul
Biots

a. Karakteristik Sputum :

b. Hasil Roentgen :
13. Interaksi sosial
Subyektif :
a. Status pernikahan:
b. Lama pernikahan:
c. Tinggal serumah dengan :
Obyektif :
a. Komunikasi verbal/nonverbal dengan orang terdekat :

14. Integritas Ego

Subyektif :
a. Perencanaan kehamilan :.....................................................
b. Perasaan klien/keluarga tentang
penyakit :.................................................................................................
................
c. Status hubungan :...........................................................
d. Cara mengatasi
stress :......................................................................................................
...........
Obyektif :
a. Status emosional (cemas, apatis, dll):............................................
b. Respon fisiologis yang
teramati :....................................................................................
c. Agama :.........................................
d. Muncul perasaaan (tidak berdaya, putus asa, tidak mampu):
…………………………………….........................................

15. Neurosensori
Subyektif :
a. Pusing (ada/tidak ada):.........................................................
b. Kesemutan/kebas/kelembaban (lokasi) :........................................

16. Keamanan :
Subyetif :
a. Alergi/sensitivitas :........................................................................
b. Penyakit masa kanak-kanak :........................................................
c. Riwayat imunisasi :.......................................................................
d. Infeksi virus terakhir :...................................................................
e. Binatang peliharaan dirumah :......................................................
f. Masalah obstetrik sebelumnya :...................................................
g. Jarak waktu kehamilan terakhir :..................................................
h. Riwayat kecelakaan : ....................................................................
i. Fraktur dislokasi :..........................................................................
j. Pembesaran kelenjar :..................................................................
Obyektif :
 a. Integritas kulit :...........................................................................
b. Cara berjalan : ............................................................................

17. Penyuluhan/pembelajaran
Subyektif :
a. Bahasa dominan :..........................................................................
b. Pendidikan terakhir :.....................................................................
c. Pekerjaan suami:............................................................................
d. Faktor penyakit dari keluarga :......................................................
e. Sumber pendidikan tentang penyakit :..........................................
f. Pertimbangan rencana pulang
g. Tanggal informasi diambil :..........................................................
Pertimbangan rencana pulang :...................................................................
Tanggal perkiraan pulang :.........................................................................
Ketersediaan sumber kesehatan terdekat : ...................................................

18. Pemeriksaan diagnostik :

19. Terapi dan pengobatan :