PROGRAM STUDI ILMU KEPERAWATAN

STIKES TENGKU MAHARATU PEKANBARU

KEPERAWATAN MATERNITAS

PENGKAJIAN GYNEKOLOGY

Tanggal Masuk : ....................................... Jam Masuk : ……………..

Ruang Kelas : ....................................... Kamar No : ……………..

Tgl Pengkajian : ....................................... Jam Pengkajian : ……………..

I. IDENTITAS

Nama Pasien : .................................... Nama Suami : ……………..

Umur : .................................... Umur : ……………..

Suku/Bangsa : .................................... Suku/Bangsa : ……………...

Agama : .................................... Agama : ……………...

Pendidikan : .................................... Pendidikan : ……………...

Pekerjaan : .................................... Pekerjaan : ……………...

Alamat : .................................... Alamat : ……………...

II. KELUHAN UTAMA

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III. RIWAYAT KESEHATAN

1. Riwayat Kesehatan Dahulu

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2. Riwayat Kesehatan Sekarang
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3. Riwayat Kesehatan Keluarga

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4. Riwayat Perkawinan

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5. Data Sosial Ekonomi

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6. Data Psikologis

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V. RIWAYAT MENSTRUASI

Haid : Teratur : ( )Ya ( ) Tidak

Dismenore : ( )Ya ( )Tidak

Warna : .....................................................................................................................

Lama : .....................................................................................................................

Bau : .....................................................................................................................

Lain-lain : .....................................................................................................................

VI. RIWAYAT KONTRASEPSI

1. Jenis Kontrasepsi yang digunakan sebelumnya:

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2. Lama Penggunaan:

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3. Keluhan:

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VII. HASIL PEMERIKSAAN

1. Tanda-tanda Vital
Tekanan Darah : .............................................mmHg
Nadi : .............................................x/menit
Pernapasan : .............................................x/menit
Suhu : .............................................C
2. BB Sebelum sakit : .............................................kg

BB Sekarang : .............................................kg

TB : .............................................cm
3. Kepala : .........................................................................................................

Mata : .........................................................................................................

Hidung : .........................................................................................................

Telinga : .........................................................................................................

Mulut : .........................................................................................................

Gigi : .........................................................................................................

4. Leher : .........................................................................................................
5. Dada

Inspeksi : .........................................................................................................

Palpasi : .........................................................................................................

Perkusi : .........................................................................................................

Auskultasi : .........................................................................................................

Pernapasan : .........................................................................................................

Jantung : .........................................................................................................

6. Abdomen

Inspeksi : .............................................................................................

Bekas Luka OP : .............................................................................................

Lain-lain : .............................................................................................

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 Auskultasi

Bising Usus : .............................................

Palpasi : .............................................................................................

Perkusi : .............................................................................................

7. Genetalia :..............................................................................................
8. Anus : .............................................................................................
9. Ekstermitas atas/bawah : .............................................................................................
10. Pola Nutrisi :
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11. Pola eliminasi

BAK : .....................................................................................................................

BAB :......................................................................................................................

12. Pola Istirahat/Tidur

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13. Data Lain-lain
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VIII. PEMERIKSAAN PENUNJANG

1. Hasil Lab : (cantumkan nilai normal)

2. USG : .....................................................................................................

3. Rongen : .....................................................................................................

4. Terapi yang didapat:

IX. STATUS GYNEKOLOGI

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 Pekanbaru, .............................

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 ANALISIS DATA

Nama klien : Ruangan :

Umur : No RM :

No Data (Symtom) Masalah Etiologi

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