FORMAT ASUHAN KEPERAWATAN

GINEKOLOGI
 ASUHAN KEPERAWATAN PADA GANGGUAN REPRODUKSI

Tanggal Kunjungan : ........................................... Jam : ........................................WIB

Ruang : ...........................................

I. PENGKAJIAN
A. Data Subjektif
1. Biodata
IBU : ................................................... PENANGGUNG JAWAB
Nama : ................................................ Nama : .....................................
Umur : ................................................ Umur : .....................................
Agama : ................................................ Agama : .....................................
Suku/Bangsa : ................................................ Suku/Bangsa : .....................................
Pendidikan : ................................................ Pendidikan : .....................................
Pekerjaan : ................................................ Pekerjaan : .....................................
Alamat : ................................................ Alamat : .....................................

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

3. Riwayat Menstruasi
 Menarche :............................................................th
 Siklus :............................................................hari, teratur/tidak
 Lama menstruasi :............................................................hari
 Banyaknya ganti pembalut :...........................................................kali/hari
 Dismenorea/tidak : ...........................................................
= Masalah khusus :…………………………………………

4. Riwayat kehamilan, persalinan dan nifas yang lalu

Anak Tanggal U Jenis Tempat Komplikasi Bayi Nifas
Ke- Lahir/Umur K Persalinan Persalinan Penolong Bayi Ibu PB/BB Keadaan Keadaan laktasi

5. Riwayat Kesehatan/Penyakit Sekarang/yang Lalu

 Jantung : .....................................................................................
 Hipertensi : .....................................................................................
 Diabetes Melitus : .....................................................................................
 Ginjal : .....................................................................................
 Asma : .....................................................................................
 Hepatitis : .....................................................................................
 HIV/AIDS : .....................................................................................
  Riwayat Operasi Abdomen/SC : .....................................................................................

6. Riwayat Penyakit Keluarga:

 Jantung : ....................................................................................................
 Hipertensi : ....................................................................................................
 Diabetes Melitus : ....................................................................................................
 Hepatitis : ....................................................................................................
 Asma : ....................................................................................................
 Ginjal : ....................................................................................................
 Riwayat bayi kembar : ....................................................................................................

7. Riwayat KB
………………………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………………

8. Riwayat Sosial Ekonomi & Psikologis

 Status Perkawinan : Kawin .......... kali
 Lama menikah .............tahun
 Umur menikah pertama kali; ................. tahun
 Respon Ibu/Suami terhadap pemakaian
 Pengambilan keputusan dalam keluarga alat kontrasepsi

9. ACTIVITY DAILY LIVING

a. Pola makan & minum
Frekuensi : ................................................................................ kali sehari
Jenis : .....................................................................................................
Porsi : .....................................................................................................
Keluhan/Pantangan : .....................................................................................................
b. Pola Istirahat
Tidur siang : ................................................................................ jam
Tidur malam : ................................................................................ jam
Keluhan : ................................................................................ jam
c. Pola eliminasi
BAK………kali/hari, konsistensi…………….., warna………………….
BAB………kali/hari, warna………………….., lendir darah:……………
d. Personal Hygiene
Mandi : ............................................................ kali sehari
Ganti pakaian dan pakaian dalam : ............................................................ kali sehari
e. Aktifitas
Pekerjaan sehari-hari : ....................................................................................................
Keluhan : ....................................................................................................
Hubungan seksual : .............................................................................. kali/minggu
f. Kebiasaan hidup
Merokok : ..............................................................................................
Minum-minuman keras : ..............................................................................................
 Konsumsi obat terlarang : ..............................................................................................
Minum jamu : ..............................................................................................

B. Data Objektif
1. Keadaan Umum : ...........................................................................................................
Tingkat Kesadaran : ...........................................................................................................

2. Tanda-tanda vital:
Tekanan darah : ...................................................................... mmHg
Nadi : ...................................................................... kali/menit
Suhu : ...............................................................................................
Respirasi : ...................................................................... kali/menit
Tinggi badan : ...................................................................... cm
Berat badan : ...................................................................... kg

3. Pemeriksaan Fisik
Inspeksi : ...............................................................................................
Postur Tubuh : ...............................................................................................
Kepala : ...............................................................................................
Rambut : ...............................................................................................
Muka: cloasma: oedeme:
Hidung: polip:
Gigi dan mulut : ...............................................................................................

4. Leher
Pembesaran kelenjar tyroid : ...............................................................................................

5. Payudara
Bentuk simetris : ...............................................................................................
Ada Benjolan atau Tidak : ...............................................................................................

6. Abdomen
Inspeksi : ...............................................................................................
Palpasi : ...............................................................................................

7. Genetalia
Varises : ..........................................................................................

8. Anus
Heaemoroid/tidak : ..........................................................................................

9. Ekstremitas (Tangan dan Kaki)

Simetris/tidak : ..........................................................................................
Oedeme pada Tungkai Bawah : ..........................................................................................
 Varises : ..........................................................................................
Pergerakan : ..........................................................................................

10. Terapi Farmakologi : ……………………………………………………………….

……………………………………………………………….
……………………………………………………………….
11. Pemeriksaan Penunjang
D. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

E. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

F. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

Mengetahui, ...............................,.......................................
Pembimbing klinik
Mahasiswa

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NIM.
ANALISIS DATA

HARI/TGL : ...............................................................................................

NO DATA ETIOLOGI MASALAH

 DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN
 RENCANA TINDAKAN KEPERAWATAN

DIAGNOSA TUJUAN DAN NAMA & TANDA

NO RENCANA INTERVENSI
KEPERAWATAN KRITERIA HASIL TANGAN
IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA &
NO TANGGAL JAM TINDAKAN KEPERAWATAN TANDA
TANGAN
 EVALUASI

DIAGNOSA TANGGAL
N KEPERAW
O
ATAN

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A: A: A:
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 DIAGNOSA TANGGAL
N KEPERAW
O
ATAN
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Mengetahui,
Pembimbing Akademik Pembimbing Lahan

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