PENGKAJIAN ASUHAN KEPERAWATAN MATERNITASPADA WANITA DENGAN
GANGGUAN SISTEM REPRODUKSI
Nama Mahasiswa:Resvia ArwindaTempat Praktek: RSUD H.Moch.Ansari
Saleh BanjarmasinTanggal:9 s/d 21 Maret 2015
I. Identitas diri KlienNama : .......Usia : .......Jenis
kelamin: .......Alamat: .......Pendidikan : .......Pekerjaan :
.......Tanggal masuk RS: .......Sumber Informasi: .......Keluarga
terdekat yang dapat segera dihubungi (orang tua, wali, suami,
istri, dll):
.............................................................................................................................................
II. Status kesehatan saat ini1. Alasan kunjungan/ keluhan
utama........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2. Faktor pencentus: .........3. Lamanya keluhan: .......4.
Timbulnya keluhan: ( ) Bertahap( ) Mendadak5. Faktor yang
memperberat: .........6. Upaya yang dilakukan untuk mengatasinya
:Sendiri: ....Oleh orang lain: 7. Diagnosa medik
:.......................................................................
tanggal...................................................................................................................
tanggal...................................................................................................................
tanggal...................................................................................................................
tanggal............................................
III. Riwayat
KeluargaGenogram.......................................................................................................................................................................
IV. Riwayat kesehatan yang lalu1. Penyakit yang pernah
dialamiKanak-kanak: ....Kecelakaan: ....Pernah dirawat:
....Operasi: ....2. Imunisasi: ........3.
Alergi:Tipe.......................................................
Reaksi...........................................................Tindakan...................................................................................................................................................................................................................................................................................................................................................................................................Kebiasaan:
merokok/kopi/obat/alkohol/lain-lain:
......................................................................................................................................4.
Obat-obatan:...........................................................................................................................5.
Lamanya:
.....................................................................................................................
V. Pemeriksaan Fisik dan Keluhan Fisik yang DialamiKeadaan Umum
:Kesadaran: Vital sign: TD = HR = ...RR = T =
KepalaBentuk: Keluhan:
Mata Ukuran pupil ..........................................
Isokor
................................................................Reaksi
terhadap cahaya: ......Akomodasi: ..Bentuk: ..Konjunktiva: ..Fungsi
penglihatan: ..Tanda-tanda radang: ..Pemeriksaan mata terakhir:
..Operasi: ..Kacamata: ..Lensa kotak: ..
Hidung Reaksi alergi: ..Cara mengatasi: ..Pernah mengalami flu:
..Frekuensi dalam setahun:
..Sinus........................................................
Perdarahan
.......................................................
Mulut dan tenggorokGigi: ..Kesulitan mengunyah/ menelan :
...Gangguan bicara: ..Pemeriksaan gigi terakhir: ..
PernafasanSuara paru: ..Pola nafas: ..Batuk: ..Sputum: ..Nyeri:
..Kemampuan melakukan aktivitas : .Baruk darah: ..Rontgen terakhir
.................................................................................................................
Hasil...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................SirkulasiNadi
perifer: ..Capilary refiling: ..Distensi vena jugularis: ..Suara
jantung: ..Suara jantung tambahan: ..Irama jantung: ..Nyeri:
..Edema: ..Palpitasi: ..Baal: ..Perubahan warna (kulit, kuk, bibir)
: ......Clubbing: ..Keadaan ekstremitas: ..Syncope: ..NutrisiBerat
badan................................................ Tinggi
Badan..Status gizi: ..Jenis diet: ..Nafsu makan: ..Rasa mual:
..Muntah: ..Intake cairan: ..
EliminasiBAB: ................Penggunaan pencahar: ..Kolostomi:
..Konstipasi: ..Diare: ..BAK: ....Pola rutin: ..Inkontinensia:
..Infeksi: ..Hematuri: ..Kateter: ..Urin output: ..
Reproduksi: Kehamilan G............... P...........
A............No. AnakGg. kehamilanProses persalinanLama
persalinanTempat persalinan/ penolong
................................................................
Masalah persalinanMasalah nifas dan laktasiMasalah bayiKeadaan
anak saat ini
........................
Pemeriksaan payudara
........................................................................................................
Keluhan payudara ........Pemeriksaan genetalia
........................................................................................................Keluhan
genetalia ........Usia menarche
....................................................................................................................Siklus
menstruasi.................................................................................................................Karakteristik
menstruasi .Menapause
..........................................................................................................................Keluhan
yang muncul selama ini Masalah yang berhubungan dengan kesehatan
reproduksi
................................................................................................................................................Sejak
kapan
.........................................................................................................................Sudah
dilakukan
apa.............................................................................................................Pembedahan
ginekologi
.......................................................................................................Kapan
..................................................................................................................................Pengaruh
pembedahan terhadap kehidupan seksualitasnya
.......................................................................................................................................................................................................................................................................................................................................................................................................................................Pemeriksaan
Pap Smear terakhir
........................................................................................Hasil
.......................................................................................................................................Keputihan
...........................................................................................................................Penggunaan
kateter
.............................................................................................................
Neurosis Tingkat
kesadaran..............................................
GCS.........................................................Disorentasi:
..Tingkah laku: ..Riwayat epilepsi/kejang/parkinson :
.......Reflex: ..
MuskuloskeletalKekuatan otot: ..Pergerakan ekstremitas: ..Nyeri:
..Kekakuan: ..Pola latihan gerak: ..
KulitWarna: ..Integritas: ..Turgor: ..
VI. Kesehatan LingkunganKebersihan: .............Bahaya:
.........Polusi: .........VII. Psikososial1. Pola pikir dan
persepsiAlat bantu yang digunakan( ) Kacamata( ) Alat bantu
pendengaranKesulitan yang dialami( ) Sering ( ) Menurunnya
sensitifitas terhadap sakit( ) Menurunnya sensitifitas terhadap
panas/ dingin( ) Membaca/ menulis
2. Persepsi diriHal yang sangat dipikirkan saat ini:
.............Harapan setelah menjalani perawatan:
.............Perubahan yang dirasa setelah sakit: .............
3. Suasana hati: .........Rentang perhatian: .....
4. Hubungan/ komunikasiBicara Bahasa Utama.....( ) Jelas( )
Relevan( ) Mampu mengekspresikan( ) Mampu mengerti orang lainTempat
tinggal .( ) Sendiri( ) Bersama orang lain, yaitu ..Kehidupan
keluarga .....Adat istiadat yang dianut ........
Pembuat keputusan dalam keluarga ......Pola komunikasi ..
Keuangan( ) Memadai( ) KurangKesulitan dalam keluarga( )
Hubungan dengan orang tua( ) Hubungan dengan sanak keluarga( )
Hubungan perkawinan5. Kebiasaan seksualGangguan hubungan seksual
disebabkan kondisi sebagai berikut:( ) fertilitas( ) menstruasi( )
libido( ) kehamilan( ) ereksi( ) alat kontrasepsiPemahaman terhadap
fungsi seksual : .......Masalah kebiasaan seksual yang dialami :
............
6. Pertahanan koping : ...Pengambilan keputusan( ) Sendiri( )
Dibantu orang lain, sebutkan: ......Yang disukai tentang diri
sendiri: ...........Yang ingin diubah dari kehidupan:
...............Yang dilakukan jika stress:( ) Pemecahan masalah( )
Makan( ) Tidur( ) Makan obat( ) Cari pertolongan( ) Lain-lain
(misal marah, diam, dll), sebutkan : .........Apakah yang dilakukan
perawat agar anda nyaman dan aman : .....
7. Sistem nilai kepercayaanSiapa atau apa sumber kekuatan :
........Apakah Tuhan, Agama, Kepercayaan penting untuk anda
.....Kegaiatan agama atau kepercayaan yang dilakukan (macam dan
frekuensi) sebutkan : .........Kegitan agama atau kepercayaan yang
ingin dilakukan selama di Rumah Sakit, sebutkan :
.........................................................................................................................8.
Tingkat Perkembangan:Usia : .......... Karakteristik :
............
Data LaboratoriumTanggal dan jenis pemeriksaanHasil pemeriksaan
dan nilai normalInterpretasi
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PengobatanTanggalJenis terapiRute terapiDosisIndikasi terapi
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Analisa DataDataKemungkinan PenyebabMasalah
........................................................................
Diagnosa Keperawatan1. ......2. ......3. ......4. ......
Rencana, Implementasi, EvaluasiTanggal / JamDiagnosa
KeperawatanTujuanIntervensiImplementasiEvaluasi
..................................................................................................................................................................
