Format Pengkajian

Pada Wanita dengan Gangguan Sistem Reproduksi

DATA SUBJEKTIF
1. Identitas/biodata

Nama Ibu : Nama Suami :

Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat Rumah : Alamat rumah :
Telepon : Telepon :

2. Keluhan Utama
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

3. Riwayat Kehamilan & Persalinan yang lalu G...........P.......A.......

No Tangga Tempat Usia Jenis penolon Penyakit Anak

. l Lahir kehamilan kehamilan g kehamilan JK BB TB Keadaan
& persalinan
4. Riwayat Kesehatan
Penyakit yang pernah/sedang diderita
No Jenis Sekarang Dahulu
.
1. Jantung
2. Hipertensi
3. Hepatitis
4. DM
5. Anemia
6. PMS
7. TBC
8. Malaria
9. Ggn Mental
10. Operasi
11. Lain-lain

Keturunan Kembar : ada/tidak : .......................Dari pihak : ....................

5. Pola fungsi kesehatan

a. Aktivitas sehari-hari
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

b. Pola nutrisi
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

c. Pola eliminasi
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

d. Pola tidur dan istirahat

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

e. Pola hygiene
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

6. Riwayat KB
Pernah menggunakan jenis KB ................................................lamanya.........................
Alasan berhenti ...............................................................................................................
Ganti cara ................................................................................. sejak..............................
Alasan .............................................................................................................................
 Status perkawinan Sah : ...............................Istri Ke .........................................

7. Riwayat Menstruasi
Menarche : .....................................
Lamanya : .....................................
Sifat darah : .....................................
Flour albus: .....................................
Siklus : ..........................................
Jumlah : ..........................................
Dismenorhea : .................................

DATA OBJEKTIF
PEMERIKSAAN FISIK
1. Kesadaran umum
....................................................................................................................................
....................................................................................................................................

2. Tanda-tanda Vital
Respirasi :.................x/menit Nadi :................x/menit
Tekanan darah:.................mmHg Suhu :................°C

3. BB sekarang : ...........kg
TB : ...........cm
IMT : ...........kg/m2

4. Rambut
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

5. Muka
....................................................................................................................................
...................................................................................................................................
...................................................................................................................................
6. Mata
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

7. Hidung
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

8. Telinga
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

9. Leher
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
 10. Dada
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

11. Mamae
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

12. Abdomen
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................

13. Genitalia
Inspeksi : .........................................................................................................
Inspekulo : .........................................................................................................
VT : .........................................................................................................

14. Ekstremitas atas

Inspeksi : .........................................................................................................
Oedema :..........................................................................................................
Varises :..........................................................................................................

15. Ekstremitas Bawah

Inspeksi : .........................................................................................................
Oedema :..........................................................................................................
Varises :..........................................................................................................

PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium

Tanggal : ............................................

Darah
....................................................................................................................................
...................................................................................................................................
Urine
....................................................................................................................................
...................................................................................................................................
Pemeriksaan penunjang lainnya
Pap Smear : .........................................................................................................
USG/Rongent : .........................................................................................................
Mamografi : .........................................................................................................
Lain-lainya : .........................................................................................................
.........................................................................................................
 ..................................................................

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Pembimbing Institusi

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