PROGRAM STUDI PROFESI NERS

INSTITUT ILMU KESEHATAN BHAKTI WIYATA KEDIRI

TAHUN 2022/2023

FOMAT PENGKAJIAN
ASUHAN KEPERAWATAN PADA GANGGUAN REPRODUKSI

NAMA MAHASIWA :
NIM :

Tanggal masuk : ……………… Jam masuk : ………………..

Ruang/kelas : ……………… No. RM : ………………..
Pengkajian tanggal : ………….. Jam : ………………..
I. PENGKAJIAN
A. Data Umum
Tanggal Pengkajian : ………………………………...
1. Initial Klien : ………………...........................
2. Alamat : ...………………………………
3. Umur :…………………………………
4. Pendidikan : .......……………………………
5. Pekerjaan : ………………………………...
6. Agama : ………………………………...
7. Suku Bangsa : ………………………………...
8. Diagnosa medis : ………………………………...
9. Nama Penanggung Jawab : ………………………...
10. Alamat Penanggung : ……………………………...
11. Umur : .......……………………………
12. Pendidikan :…………………………………
13. Pekerjaan : ……………………………...…
14. Agama : ………………………………...
15. Suku Bangsa :....………………………………

B. Keluhan Utama
...........................................................................................................................................
...........................................................................................................................................
............
C. Status Kesehatan atau penyakit saat ini
1. Gejala awal :
.....................................................................................................................................
.....................................................................................................................................
............
2. Timbulnya gejala
a. Faktor yang mempengaruhi gejala
.....................................................................................................................................
.....................................................................................................................................
............
b. Faktor yang memperburuk gejala
.....................................................................................................................................
.....................................................................................................................................
............
3. Deskripsi gejala
a. Lokasi : ..............................................................................................................
.........
b. Kualitas : ...............................................................................................................
......
c. Kuantitas : .............................................................................................................
......
4. Efek gaya Hidup
: ...........................................................................................................
D. Riwayat Ginekologi
1. Karakteristik mentruasi
.....................................................................................................................................
.....................................................................................................................................
............
2. Menarche
.....................................................................................................................................
.....................................................................................................................................
............
3. Perdarahan tengah siklus
.....................................................................................................................................
.....................................................................................................................................
............
4. Kontrasepsi
.....................................................................................................................................
.....................................................................................................................................
............
5. Penyakit Menular seksual
.....................................................................................................................................
.....................................................................................................................................
............
E. Riwayat medis yang lalu
1. Penyakit dan pengobatan
.....................................................................................................................................
.....................................................................................................................................
..........
2. Alergi
.....................................................................................................................................
.....
Penyakit masa kanak – kanak dan imunisasi
.....................................................................................................................................
.....................................................................................................................................
..........
3. Penyakit dan pembedahan sebelumnya
.....................................................................................................................................
.....................................................................................................................................
............
4. Riwayat di rumah sakit sebelumnya
.....................................................................................................................................
.....
5. Kecelakaan atau cidera
.....................................................................................................................................
.....................................................................................................................................
..........
6. Perilaku beresiko
a. Konsumsi kafein
b. Merokok
c. Alkohol
d. Obat – obatan
e. Praktis seks tidak aman
7. Riwayat kekerasan / penganianyaan
a. Cidera akibat kekerasaan
b. Pengalaman perkosaan
c. Kesimpulan

F. Riwayat Kesehatan Keluarga

1. Penyakit Keturunan
..............................................................................................................................
 2. Penyakit saat ini dalam keluarga
..............................................................................................................................
3. Riwayat penyakit jiwa dan keluarga
..............................................................................................................................
4. Genogram

G. Riwayat Psikososial
1. Koping individu
a. Kesadaran diri dan harga diri
..........................................................................
b. Penatalaksanaan stress
..........................................................................
c. Penyalahgunaan zat
..........................................................................
2. Pola kesehatan
a. Nutrisi
............................................................................................................................
............................................................................................................................
..........
b. Personal Hygiene
............................................................................................................................
............................................................................................................................
..........
c. Aktivitas dan latihan
.............................................................................................................................
.............................................................................................................................
..........
d. Rekreasi
.............................................................................................................................
.............................................................................................................................
..........
3. Spiritual
a. Agama ................................................................................................................
......
b. Pola
Beribadah .........................................................................................................
H. Pemeriksaan Fisik
1. Keadaan
Umum ...............................................................................................................
2. Kesadaran .................................................................................................................
.......
3. Tanda – tanda
Vital .........................................................................................................
4. Head To Toe (Dari kepala s/d kaki)
Kepala
 Rambut : Warna , bersih atau tidak, rontok atau tidak
...........................................................................................................................................
...........................................................................................................................................
...........
 Alis : Mudah dicabut atau tidak
...........................................................................................................................................
...........................................................................................................................................
...........
 Mata : Keadaan konjungtiva, sklera
...........................................................................................................................................
...........................................................................................................................................
...........
 Muka : Oedema atau tidak, khususnya di pagi hari
...........................................................................................................................................
...........................................................................................................................................
...........
 Hidung : Kebersihan, ada polip atau tidak
...........................................................................................................................................
...........................................................................................................................................
...........
 Mulut : Warna bibir, ada stomatitis atau tidak
...........................................................................................................................................
...........................................................................................................................................
...........
 Gigi : Kebersihan, ada karies atau tidak, ada ginggivitas atau tidak
...........................................................................................................................................
...........................................................................................................................................
.............
 Telinga : Kesimetrisan, kebersihan, ada serumen atau tidak
...........................................................................................................................................
...........................................................................................................................................
.............
 Leher : Dikaji adakah pembesaran kelenjar thyroid, dan vena jugularis
...........................................................................................................................................
...........................................................................................................................................
...........

 Dada dan axilla : ada pembesaran kelenjar limfe atau tidak

...........................................................................................................................................
...........................................................................................................................................
.............
 Mamae : masih teraba lunak pada hari I dan II post partum, mulai keluar
Kolustrum, hari III hangat dan berisi , hari IV keras dan produksi ASI meningkat
...........................................................................................................................................
...........................................................................................................................................
.............
 Puting : penonjolan puting , monthgomeri, pengeluaran colostrum
...........................................................................................................................................
...........................................................................................................................................
 Abdomem : ada bekas luka Operasi atau tidak, adakah pembesaran hati dan lien
serta keadaan kandung kemih, adanya linea nigra, striae gravidarum, TFU, kontur
kulit, palpasi supra pubik untuk mendeteksi bladder distensi, kontraksi uterus
...........................................................................................................................................
...........................................................................................................................................

 Ekstermitas
Superior : Kesimetrisan, keadaan kuku ( bersih atau tidak, panjang atau
pendek, pucat atau tidak )
...........................................................................................................................................
...........................................................................................................................................
.............
 Inferior : Keseimetrisan , keadaan kuku ( bersih atau tidak, panjang atau tidak,
pucat atau tidak, ada varices atau tidak ada tromboplebitis atau tidak )
...........................................................................................................................................
...........................................................................................................................................
.............
 Genetalia
- Perinium : Intack, ruptur, episiotomi, tanda – tanda REEDA ), jenis episiotomi
- Lochea
- Rectum
...........................................................................................................................................
...........................................................................................................................................
.............

I. Pemeriksaan Penunjang
1. Laboratorium Tanggal .............................
2. Diagnostik Tanggal .............................
3. Terapi
4. Diet

J. Kesimpulan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
............................