ASUHAN KEBIDANAN GANGGUAN SISTEM REPRODUKSI

PADA .............. DENGAN........

DI .........................................................................

Tempat Praktek/Ruang : ……………………………………………….................……

Nomor MR : ……………………………………………….................……
Masuk RS/klinik. H/Tgl : ……………………………………………….................……
Pembimbing lahan/CI : ……………………………………………….................……
Pengkajian tanggal : ……………………… Jam ………… Oleh ……………………….
Sumber data : ………………………………………………………………………

I. PENGKAJIAN DATA
A. Data Subyektif
1. Identitas Istri Suami
Nama : ……………………… ………………………
Umur : ……………………… ………………………
Agama : ……………………… ………………………
Suku/Bangsa : ……………………… ………………………
Pendidikan : ……………………… ………………………
Pekerjaan : ……………………… ………………………
Alamat : ……………………… ………………………

2. Anamnesa
a. Keluhan Utama :
.................................................................................................................................
Riwayat Perkawinan :
.................................................................................................................................
Riwayat Haid :
Menarche umur ............. tahun, siklus ............. hari, teratur / tidak, sakit / tidak,
Lamanya ................. hari, sifat darah encer / beku, bau ........................
Keluhan ............................................................. HPM ..........................
b. Riwayat Obstreri (G ...... P ...... Ab ...... Ah ......)
Proses Bayi
No Kehamilan Persalinan BBL Jenis H/ Nifas Perdarahan Ket
Penolong Kelamin M

c. Riwayat KB
 Mulai Pakai Berhenti / Ganti Cara
No Alat / Alasan Ket
. Cara Tgl/Bln/ Tgl/Bln/
Th Oleh Di Th Oleh Di

d. Riwayat Kesehatan
................................................................................................................................
................................................................................................................................

e. Pola Pemenuhan Kebutuhan Sehari-hari :

1) Nutrisi
a) Makan : .........................................................................
b) Minum : .........................................................................
2) Eliminasi
a) BAK : .........................................................................
b) BAB : .........................................................................
3) Istirahat
a) Tidur siang : .........................................................................
b) Tidur malam : .........................................................................
4) Aktifitas
5) Personal hygiene : .........................................................................
6) Seksualitas : .........................................................................
f. Data psikososial, spiritual : .........................................................................

B. Data Obyektif
1. Pemeriksaan Umum
Keadaan umum : ......................... Tekanan darah: .........................
Kesadaran : ......................... Nadi : .........................
BB : ......................... Suhu : .........................
TB : ......................... Respirasi : .........................
BB : ......................... Status Gizi : .........................
2. Pemeriksaan Khusus
 Kepala : .....................................................................................
 Mata : .....................................................................................
 Muka : .....................................................................................
 Hidung : .....................................................................................
  Mulut : .....................................................................................
 Telinga : .....................................................................................
 Leher : .....................................................................................
 Dada : .....................................................................................
 Perut : .....................................................................................
 Ekstremitas atas : .....................................................................................
 Ekstremitas bawah : .....................................................................................
 Vulva : .....................................................................................
3. Pemeriksaan Ginekologi
 Pemeriksaan Inspekulo : .....................................................................................
 Periksa Dalam : .....................................................................................

C. Data Penunjang
 Laboratorium : .....................................................................................
 Pemeriksaan Radiologis : .....................................................................................
 Pap Smear : .....................................................................................
 Dan lain-lain : .....................................................................................

II. INTERPRETASI DATA

DS : ..........................................................................................................................
DO : ..........................................................................................................................

III. DIAGNOSA / MASALAH POTENSIAL

IV. INTERVENSI
V. PERENCANAAN
VI. PELAKSANAAN
VII. EVALUASI

Pembimbing Akademik Pembimbing Lahan/CI Mahasiswa

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