Nama Mahasiswa :……….

NIM :……….

FORMULIR PENGKAJIAN GANGGUAN REPRODUKSI

KEPERAWATAN MATERNITAS
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KESEHATAN
UNIVERSITAS GRESIK

Tanggal masuk : Jam masuk :

Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

A. IDENTITAS
1. Nama pasien : ................................. Nama Suami : ……......Ke........
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ……...................
4. Agama : ................................. Agama : ...........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Perkawinan :....................... Lama menikah: ………………...

B. STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................
……......................................................................................................................................
..............................................................................................................................................
..........................................................................................
2. Keluhan utama saat ini :
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
3. Timbulnya keluhan : ( ) bertahap, ( ) mendadak
4. Faktor yang memperberat :
……………………………………………………………………………………………
…………………………………………………………………………………………......
5. Upaya yang dilakukan untuk mengatasi :
……………………………………………………………………………………………
…………………………………………………………………………………………......
6. Diagnosa medik : ...........................................................................……....................

C. RIWAYAT KEPERAWATAN

1. RIWAYAT OBSTETRI :
1. Riwayat menstruasi :
 Menarche : umur.................... Siklus : teratur ( ) tidak (
)
 Banyaknya : ............................ Lamanya : ...........................
 HPHT : ............................ Keluhan : ...........................

2. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak
Umur
No Tahun Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
kehamilan

1
2
 3. Genogram :

2. RIWAYAT KELUARGA BERENCANA :

 Melaksanakan KB : ( ) ya ( ) tidak
 Bila ya jenis kontrasepsi apa yang pernah atau sedang
digunakan : ......................................................
 Sejak kapan menggunakan
kontrasepsi : ...............................................................
 Masalah yang
terjadi : ............................................................................................

3. RIWAYAT KESEHATAN :
 Penyakit yang pernah dialami
ibu : ........................................................................
 Pengobatan yang
didapat : ......................................................................................
 Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya: sebutkan ...........................................................................

4. RIWAYAT LINGKUNGAN :
- Kebersihan : ...........................................................................................................
- Bahaya : …………...........................................................................................
- Lainnya sebutkan : .................................................................................……......

5. ASPEK PSIKOSOSIAL :
1. Bagaimana pendapat ibu tentang penyakit saat ini : …………….... ………….
2. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari?
Bila ya bagaimana ..................................................................................................
3. Bagaimana dukungan pasangan terhadap keadaan saat ini :………………….
4. Bagaimana sikap anggota keluarga lainnya terhadap keadaan saat
ini : ............ ...........................................................................
5. Lainnya sebutkan:……………………...................................................................

6. KEBUTUHAN DASAR KHUSUS :

1. Pola Nutrisi
 Frekwensi makan : .............................. x sehari
 Nafsu makan : ( ) baik, ( ) tidak nafsu,
alasan ..........................................
 Jenis makanan

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 rumah : ................................................................................….
 Makanan yang tidak disukai/ alergi/
pantangan : .............................................

2. Pola eliminasi :
 BAK
- Frekwensi : ....................kali
- Warna : .......................
……………………………………………….
- Keluhan saat BAK : .................................................
………......................

 BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : .............
……………………………………………….........
- Keluhan
: ..............................................................................
………....
3. Pola personal hygiene
 Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
 Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
 Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
4. Pola istirahat dan tidur
 Lama tidur : ............................jam/hari
 Kebiasaan sebelum
tidur : ................................................................................
 Keluhan : .................................................................................................
.........

5. Pola aktifitas dan latihan

 Kegiatan dalam
pekerjaan : ..............................................................................
 Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
 Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
 Kegiatan waktu
luang : .....................................................................................
 Keluhan dalam
beraktifitas : ............................................................................

6. Pola kebiasaan yang mempengaruhi kesehatan

 Merokok : ....................................................................................
 Minuman keras : ....................................................................................

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  Ketergantungan obat
: ....................................................................................

7. PEMERIKSAAN FISIK
 Keadaan umum : ......................................Kesadaran : .........................
 Tekanan darah : ......................................Nadi
: .............x/menit
 Respirasi : ......................................Suhu : .......…........C
 Berat badan : ......................kg Tinggi
badan : ................cm

Kepala, mata kuping, hidung dan tenggorokan :

Kepala : Bentuk ..........................................................
Keluhan :........................................................

Mata :
 Kelopak mata : ......................................................................
 Gerakan mata : ......................................................................
 Konjungtiva : ......................................................................
 Sklera : ......................................................................
 Pupil : ......................................................................
 Akomodasi : ......................................................................
 Lainnya sebutkan : ......................................................................

Hidung :
 Reaksi alergi
: ..............................................................................................
 Sinus
: ..............................................................................................
 Lainnya sebutkan
:...............................................................................................

Mulut dan Tenggorokan :

 Gigi geligi
: .............................................................................................
 Kesulitan
menelan : ..............................................................................................
 Lainnya sebutkan
:...............................................................................................

Dada dan Axilla

 Mammae : membesar ( ) ya ( ) tidak
 Areolla
mammae : ..................................................................................................
 Papila
mammae :...................................................................................................
 Colostrum : ...................................................................................
..............

Pernafasan
 Jalan
nafas : .....................................................................................................
 Suara
nafas . : ....................................................................................................
 Menggunakan otot-otot bantu
pernafasan : ............................................................

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  Lainnya
sebutkan : .................................................................................................

Sirkulasi jantung
 Kecepatan denyut apical : ...............................x/menit
 Irama : ................................................................................
...............
 Kelainan bunyi
jantung : ........................................................................................
 Sakit
dada : ...............................................................................................
 Timbul .: ................................................................................
...............
 Lainnya
sebutkan : ..............................................................................................
Abdomen
 Mengecil : .................................................................................
...............
 Linea dan
striae : ...............................................................................................
 Luka bekas
operasi : ...............................................................................................
 Kontraksi : .................................................................................
...............
 Lainnya
sebutkan : ................................................................................................

Genitourinary
 Perineum /
Vulva : ...............................................................................................
 Vesika
Urinasria : ...............................................................................................
 Lainnya
sebutkan : ..............................................................................................

Ekstrimitas (integumen/muskuloskeletal)
 Turgor kulit : .............................................………………………………...
 Warna kulit : .................................................................................................
 Kontraktur pada persendian ekstrimitas : .........................................................
 Kesulitan dalam pergerakan : .........................................................................
 Lainnya sebutkan : ...........................................................................................

D. DATA PENUNJANG
1) Laboratorium : .....................................................................................
............
2) USG
: .................................................................................................
3) Rontgen : .....................................................................................
............
4) Terapi yang
didapat: .............................................................................................................
...........................................................................................................................
...........................................................................................................................
..........

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E. DATA TAMBAHAN
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

Gresik, ........................................
Pemeriksa

(..................................................)