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DEPARTEMEN PENDIDIKAN NASIONALPROGRAM STUDI ILMU KEPERAWATAN
FK UNAIR SURABAYA
FORMAT PENGKAJIANGANGGUAN SISTEM REPRODUKSI
UNIT KEPERAWATAN MATERNITAS
Tanggal masuk : Jam masuk :Ruang/kelas : Kamar No :Pengkajian tanggal : Jam :
A. IDENTITAS1. Nama pasien : ................................. Nama Suami :
…….....................2. Umur : ....................... th Umur
: ....................... th3. Suku/ bangsa : ................................. Suku/ bangsa :
……...................4. Agama : ................................. Agama
: ...........................5. Pendidikan : .................................. Pendidikan
: ...........................6. Pekerjaan : .................................. Pekerjaan
: ...........................7. Alamat : .................................. Alamat
: ...........................8. Status ..................................................
B. STATUS KESEHATAN SAAT INI 9. Alasan kunjungan ke rumah
sakit : ...................................................................................................................................................................................................................………………………………………………………………………
10. Keluhan utama saat ini : ......................................................................................
.............................................................................................................................
.................………………………………………………………………………11. Timbulnya keluhan : ( ) bertahap, ( ) mendadak12. Faktor yang
memperberat : ..............................................................................................................................................................................................................................……………………………………………………………………….
13. Upaya yang dilakukan untuk mengatasi : ...........................................................
.............................................................................................................................
...............………………………………………………………………………..14. Diagnosa
medik : ................................................................................................
C. RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :a. Riwayat menstruasi :
Menarche : umur.................... Siklus : teratur ( ) tidak ( )
Banyaknya : ............................ Lamanya: ...........................
HPHT : ............................ Keluhan: ...........................
b. Riwayat kehamilan, persalinan, nifas yang lalu :Anak ke Kehamilan Persalinan Komplikasi nifas Anak
No TahunUmur
kehamilanPenyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB pj
c. Genogram :
2. RIWAYAT KELUARGA BERENCANA : Melaksanakan KB : ( ) ya ( ) tidak Bila ya jenis kontrasepsi apa yang
digunakan : ...................................................... Sejak kapan menggunakan
kontrasepsi : ................................................................ Masalah yang
terjadi : ............................................................................................
3. RIWAYAT KESEHATAN : Penyakit yang pernah dialami
ibu : ........................................................................ Pengobatan yang
didapat : ...................................................................................... Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus( ) Penyakit jantung( ) Penyakit hipertensi( ) Penyakit lainnya : sebutkan ......................................................................
4. RIWAYAT LINGKUNGAN :- Kebersihan : ...........................................................................................................…………….......- Bahaya : …………......................................................................................................................- Lainnya sebutkan : .................................................................................…………………….....................
5. ASPEK PSIKOSOSIAL :a. Persepsi ibu tentang keluhan/ penyakit : ................................................................b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-
hari ?............Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................d. Ibu tinggal dengan
siapa : .......................................................................................e. Siapakah orang yang terpenting bagi ibu................................................................f. Sikap anggota keluarga terhadap keadaan saat ini .................................................g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. KEBUTUHAN DASAR KHUSUS :a. Pola Nutrisi
Frekwensi makan : .............................. x sehari Nafsu makan : ( ) baik, ( ) tidak nafsu,
alasan .......................................... Jenis makanan
rumah : ................................................................................…. Makanan yang tidak disukai/ alergi/
pantangan : .............................................
b. Pola eliminasi : B A K
- Frekwensi : ....................kali- Warna : .......................
……………………………………………….- Keluhan saat BAK : .................................................
………......................
B A B- Frekwensi : ....................kali- Warna : ..........................- Bau : ..........................- Konsistensi : .............
……………………………………………….........- Keluhan
: ..............................................................................………....
c. Pola personal hygiene Mandi
- Frekwensi : ...................................x /hari- Sabun : ( ) ya, ( ) tidak
Oral hygiene- Frekwensi : ...................................x /hari- Waktu : ( ) ya, ( ) tidak
Cuci rambut- Frekwensi : ...................................x /hari- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur Lama tidur : ............................jam/hari Kebiasaan sebelum
tidur : ................................................................................ Keluhan : .................................................................................................
.........
e. Pola aktifitas dan latihan Kegiatan dalam
pekerjaan : .............................................................................. Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan Merokok : .....................................................................................
......... Minuman keras
: .............................................................................................. Ketergantungan obat
: ..............................................................................................
7. PEMERIKSAAN FISIK Keadaan umum : ......................................Kesadaran : ......................... Tekanan darah : ......................................Nadi
: .............x/menit Respirasi : ......................................Suhu : .......…........C Berat badan : ......................kg Tinggi
badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata : Kelopak
mata : ..................................................................................................... Gerakan
mata : .................................................................................................... Konjungtiva : ......................................................................................
............... Sklera : ....................................................................................
................ Pupil : ......................................................................................
............... Akomodasi : ......................................................................................
............... Lainnya
sebutkan : .................................................................................................
Hidung : Reaksi
alergi : ..................................................................................................... Sinus : .....................................................................................
............... Lainnya
sebutkan : .................................................................................................
Mulut dan Tenggorokan : Gigi
geligi : ..................................................................................................... Kesulitan
menelan : ................................................................................................ Lainnya
sebutkan : .................................................................................................
Dada dan Axilla Mammae : membesar ( ) ya ( ) tidak Areolla
mammae : .................................................................................................. Papila
mammae : .................................................................................................... Colostrum : ......................................................................................
...............
Pernafasan Jalan
nafas : ..................................................................................................... Suara
nafas . : .................................................................................................... Menggunakan otot-otot bantu
pernafasan : ............................................................ Lainnya
sebutkan : .................................................................................................
Sirkulasi jantung Kecepatan denyut apical : ...............................x/menit Irama : ................................................................................
............... Kelainan bunyi
jantung : ........................................................................................ Sakit
dada : ............................................................................................... Timbul .: ................................................................................
............... Lainnya
sebutkan : ..............................................................................................
Abdomen Mengecil : .................................................................................
............... Linea dan
striae : ............................................................................................... Luka bekas
operasi : ............................................................................................... Kontraksi : .................................................................................
............... Lainnya
sebutkan : ................................................................................................
Genitourinary Perineum : ................................................................................
............... Vesika
Urinasria : ............................................................................................... Lainnyasebutkan : ................................................................................
...............
Ekstrimitas (integumen/muskuloskeletal) Turgor kulit : .............................................………………………………... Warna kulit : ................................................................................................. Kontraktur pada persendian ekstrimitas : ......................................................... Kesulitan dalam pergerakan : ......................................................................... Lainnya sebutkan : ...........................................................................................
d. Data Penunjang1) Laboratorium : .....................................................................................
............2) USG
: .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat : .................................................................................................................................................................................................................................................................................................................................................................................
e. Data Tambahan............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Surabaya, ........................................Pemeriksa
( ..................................................)
