FORMAT PENGKAJIAN GSR

A. Identitas Klien
1. Nama : __________________________________________________
2. Umur : __________________________________________________
3. Alamat : __________________________________________________
4. Agama : __________________________________________________
5. Suku Bangsa : __________________________________________________
6. Status Perkawinan : __________________________________________________
7. Pekerjaan : __________________________________________________
8. Pendidikan : __________________________________________________
9. Status Obstetri : __________________________________________________
B. Keluhan Utama
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C. Riwayat Keluhan Utama
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D. Riwayat Kesehatan Sekarang

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E. Riwayat Kesehatan Keluarga (Genogram)

F. Riwayat Obstetri
Kehamilan Gangguang Cara Masalah Penolong Masalah Masalah Keadaan
Ke- Kehamilan Persalinan Persalinan Persalinan Nifas Bayi Anak

G. Riwayat Menstruasi
1. Manarche Usia: ______________________________________________________
2. Siklus Menstruasi :_________________hari, lama menstruasi :______________hari
3. Adakah keluhan nyeri haid ? jika ya bagaimana cara mengatasinya
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4. Banyaknya
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H. Keluarga Berencana
1. Jumlah anak yang direncanakan : ________________________________________
2. Jenis kontrasepsi yang pernah digunakan : _________________________________

No Jenis Kontrasepsi Lama Penggunaan Keluhan Alasan ganti

3. Adakah gangguang atau masalah dengan kontrasepsi tersebut, bila ada bagaimana
cara mengatasisnya.
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I. Kebutuhan Dasar Khusus :
1. Oksigenasi
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2. Nutrisi
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3. Cairan
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4. Eliminasi
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5. Kenyamanan
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 6. Pengetahuan
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J. Pemeriksaan Fisik (Head To Toe)
1. Antropometri
TB : __________________________________________________
BB Sebelum sakit : __________________________________________________
BB Saat ini : __________________________________________________
Lingkar Lengan : __________________________________________________
2. Tanda Vital : Tekanan Darah: ____________________________________________
Nadi : ____________________________________________
Respirasi : ____________________________________________
Suhu : ____________________________________________
Kepala :
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Mata :
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Hidung :
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Telinga :
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Leher :
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 Jantung :
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Paru-paru :
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Payudara :
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Abdomen (secara umum dan pemeriksaan obstetrik)
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Perianal : ____________________________________________________________
Anus : _____________________________________________________________
Ekstremitas : _________________________________________________________
Kulit, Kuku : _________________________________________________________
Refleks Patella: ________________________________________________________
K. Pengkajian Psikososial
1. PenerimaanIbu terhadap penyakitnya
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2. Dukungan Keluarga
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 3. Upaya keluarga dalam menyiapkan kebutuhan terhadap perubahan peran ibu
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4. Bagaimana perasaan ibu dengan perubahan peran karena proses penyakit dan
hospitalisasi?
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J. Pemeriksaan Penunjang
1. Pemeriksaan Laboratorium :
Tanggal, Hasil

2. Pemeriksaan Urinalisis :
Tanggal, Hasil

3. USG :

4. Biopsi Serviks :

5. Dll :
K. Therapy (Oral, Injeksi, Kemotherapy, dll)
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L. Diagnosa Keperawatan
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