LAPORAN PENDAHULUAN GSR

1. KONSEP DASAR PENYAKIT

A. DEFINISI
B. KLASIFIKASI
C. ETIOLOGI
D. PATOFISIOLOGI
E. PEMERIKSAAN PENUNJANG
F. KOMPLIKASI
G. PENANGANAN

2. KONSEP ASUHAN KEPERAWATAN

A. PENGKAJIAN
B. DIAGNOSA KEPERAWATAN
C. RENCANA
KEPERAWATAN DAFTAR
PUSTAKA
 Pengkajian Gangguan Sistem Reproduksi (GSR)

Nama mahasiswa : ……………………… Tanggal pengkajian :………………………

NIM : ………………………………………….. Ruangan/RS : ………………………………...

I. Data umum klien

No. Reg : ......................................................................................................

Inisial : ...........................................................................................................

Alamat : ......................................................................................................

Tgl masuk RS : .............................................................................................

Tgl pengkajian : ............................................................................................

Tindakan medis : ..........................................................................................

II. Masalah utama

Keluhan utama : .............................................................................................

Riwayat keluhan utama

mulai timbulnya : .............................................................................................

sifat keluhan : ...............................................................................................

lokasi keluhan : ..............................................................................................

faktor pencetus : .............................................................................................

keluhan lain : ...................................................................................................

pengaruh keluhan terhadap aktivitas/fungsi tubuh : ......................................

usaha klien untuk mengatasinya : .......................................................................

III. Pengkajian Fisik

Seksualitas

Subyektif :

Usia menarche............tahun

Siklus haid...................hari

Durasi haid..................hari

Dismenorea Polimenorea Olig omenorea

Menometroragie Amenorea

Rabas pervagina : warna : ............................................

Jumlah : .........................................

Berapa lama : ................................

Metode kontrasepsi terakhir : .......................................

Status obstetri : G : ......................... P : .......................A : ........................

Riwayat persalinan :

Term penuh :................. Prematur : ................

Multiple : .......................

Riwayat persalinan terakhir :

Tahun :.......................... tempat : ...................

Lama gestasi : .............. lama persalinan : ................................

Jenis persalinan : ......................................................................

Berat badan bayi................gr

Komplikasi maternal/bayi : ..........................................................

Obyektif :

PAP smear terakhir (tgl dan hasil) : ............................................................

Tes serologi (tgl dan hasil) : ......................................................................

Makanan dan Cairan

Subyektif :

Masukan oral 4 jam terakhir : .....................................................................

Mual /muntah Hilang nafsu makan Masalah mengunyah Pola

makan :

Frekuensi.............x/hari

Konsumsi cairan......................../hari

Obyektif :

BB..................kg

TB..................cm

Turgor kulit : .................................................................................................

Membran mukosa mulut : .............................................

Kebutuhan cairan : .....................................................................

Pemeriksaan Hb, Ht (Tgl dan hasil) : ........................................

Eliminasi

Subyektif :

Frekuensi Defekasi : ..................................................................

Penggunaan Laksatif : ..............................................................

 Waktu Defekasi terakhir : ...........................................................

Frekuensi berkemih : .................................................................

Karakter urine : ..........................................................................

Nyeri/rasa terbakar/kesulitan berkemih : ..................................

Riwayat penyakit ginjal : ...........................................................

Penyakit kandung kemih : ........................................................

Penggunaan Diuretik : ...............................................................

Obyektif :

Pemasangan kateter : ..................................................................

Bising usus : ................................................................................

Karakter urine : ..........................................................................

Konsistensi feces : ....................................................................

Warna Feces : ............................................................................

Haemoroid : ...............................................................................

Palpasi Kandung kemih (teraba/tidak teraba) : ..........................

Aktivitas/istirahat

Subyektif :

Pekerjaan : ............................................................................

Hobby : ...................................................................................

Tidur malam (jam) : .................................................................

Tidur siang (jam) : ........................................................................

Obyektif :

Status neurologis : ....................................................................................

GCS : ........................................................................................................

Pengkajian Neuromuskuler :

Muscle Stretch refleks (Bisep/trisep/brachioradialis/patela/axiles) : ............

Rentang pergerakan sendi (ROM) : ...................................................................

Derajat kekuatan otot : ............................................................................

Kuku (warna) : .................................................................................................

Tekstur : ..........................................................................................................

Membran Mukosa : ........................................................................................

Konjungtiva : .....................................................................................................

Sklera : ...........................................................................................................

Hygiene

Subyektif :

Kebersihan rambut (frekuensi) : ............................................................................

Kebersihan badan : ............................................................................................

Kebersihan gigi/mulut : ......................................................................................

Kebersihan kuku tangan dan kaki : ............................................................................

Objektif :
 Cara berpakaian : ..............................................................................................

Kondisi kulit kepala : .........................................................................................

Sirkulasi

Subyektif

Riwayat penyakit jantung : ............................................................................

Riwayat demam reumatik : ............................................................................

Obyektif :

Tekanan darah : ............................................................................

Nadi : ...........................................................................................

Distensi vena jugularis (ada/tidak ada) : ..........................................................

Bunyi jantung : ............................................................................................

Frekuensi : ................................................................................................

Irama (teratur/tidak teratur) : ............................................................................

Kualitas (kuat/lemah/Rub/Murmur) : .................................................................

Ektremitas :

Suhu (hangat/akral dingin) : ............................................................................

CRT : ...............................................................................................................

Varises (ada/tidak ada) : CRT : .........................................................................

Nyeri/ketidaknyamanan

Subyektif :

Lokasi : .............................................. .............................

 Intensitas (skala 0-10): ...................................................

Frekuensi : .......................................................................

Durasi : ............................................................................

Faktor pencetus : .............................................................

Cara mengatasi : ..........................................................................................

Faktor yang berhubungan : ..........................................................................

Objektif :

Wajah meringis

Melindungi area yang sakit

Fokus menyempit

Pernafasan

Subyektif :

Dispnoe Batuk/sputum Riwayat Bronkhitis

Asma Tuberkulosis Emfisema

Pneumonia berulang Perokok, lamanya............tahun

Penggunaan alat bantu pernafasan (O2)..........L/menit

Obyektif :

Frekuensi.................x/menit

Irama : Eupnoe Tachipnoe Bradipnoe

Apnoe Hiperventilasi Cheynestokes

Kusmaul Biots
 Bunyi nafas Bronchovesikuler Vesikuler Bronchial
:

Karakteristik sputum :

Hasil rontgen :

Interaksi sosial

Subyektif

Satus pernikahan : ..........................................................................

Lama pernikahan : ..........................................................................

Tinggal serumah dengan : ..........................................................................

Obyektif

Komunikasi verbal/nonverbal dengan orang terdekat : ..................................................

Integritas ego

Subyektif

Perencanaan kehamilan : ..........................................................................

Perasaan klien/keluarga tentang penyakit : ..................................................

Status hubungan : ..........................................................................

Masalah keuangan : ..........................................................................

Cara mengatasi stres : ..........................................................................

Obyektif

Status emosional (cemas,apatis, dll) : .....................................................................

Respon fisiologis yang teramati : ..........................................................................

Agama : ..........................................................................
 Muncul perasaan (tidak berdaya, putus asa, tidak mampu) : ..................................

Neurosensori

Subyektif

Pusing (ada/tidak ada): ..........................................................................

Kesemutan/kebas/kelembaban (lokasi) .....................................................................

Keamanan

Subyektif :

Alergi/sensitivitas : ..........................................................................

Penyakit masa kanak-kanak : .....................................................................

Riwayat imunisasi : ..........................................................................

Infeksi virus terakhir : ..........................................................................

Binatang peliharaan dirumah : ..........................................................................

Masalah obstetrik sebelumnya : ..........................................................................

Jarak waktu kehamilan terakhir : ..........................................................................

Riwayat kecelakaan : ..........................................................................

Fraktur dislokasi : ..........................................................................

Pembesaran kelenjar : ..........................................................................

Obyektif

Integritas kulit : ..........................................................................

Cara berjalan : ..........................................................................

Penyuluhan/pembelajaran
Subyektif

Bahasa dominan : ..........................................................................

Pendidikan terakhir : ..........................................................................

Pekerjaan suami : ..........................................................................

Faktor penyakit dari keluarga : ..........................................................................

Sumber pendidikan tentang penyakit : .................................................................

Pertimbangan rencana pulang

Tanggal informasi diambil : ..........................................................................

Pertimbangan rencana pulang : ..........................................................................

Tanggal perkiraan pulang : ..........................................................................

Ketersediaan sumber kesehatan terdekat : ..................................................................

Pemeriksaan diagnostik :

Terapi dan pengobatan :

 FORMAT ASUHAN KEPERAWATAN

1. Pengkajian sesuai dengan bagian

2. Analisa Data

NO DATA ETIOLOGI MASALAH KEPERAWATAN

DS:

DO:
3. Rencana Intervensi
Diagnosa Keperawatan LUARAN Rencana intervensi

DS:
DO:
Ditandai
dengan/berhubungan dengan

4. Implementasi dan evaluasi

HARI/TANGGAL/JAM NO.DIAGNOSA IMPLEMENTASI EVALUASI