DEPARTEMEN PENDIDIKAN NASIONAL PROGRAM STUDI ILMU KEPERAWATAN FK UNAIR SURABAYA FORMAT PENGKAJIAN GANGGUAN SISTEM REPRODUKSI UNIT KEPERAWATAN MATERNITAS Tanggal masuk Ruang/kelas Pengkajian tanggal 1. : : : Jam masuk Kamar No Jam : : : Nama Suami : Umur Suku/ bangsa : Agama Pendidikan Pekerjaan Alamat

IDENTITAS 1. Nama pasien : ................................. ..................... 2. Umur : ....................... th : ....................... th 3. Suku/ bangsa : ................................. ................... 4. Agama : ................................. : ........................... 5. Pendidikan : .................................. : ........................... 6. Pekerjaan : .................................. : ........................... 7. Alamat : .................................. : ........................... 8. Status ..................................................

2. STATUS KESEHATAN SAAT INI 1. Alasan kunjungan ke rumah sakit : .............................................................. ..... 2. Keluhan utama saat ini : ............................................. .......................................... Timbulnya keluhan : ( ) bertahap, ( ) mendadak.

3. 4.

Faktor yang memperberat : ......................................................................... ...... Upaya yang dilakukan untuk mengatasi : ............................................ ............... Diagnosa medik : ....................................... ........................................................ RIWAYAT KEPERAWATAN

5.

6.

3.

1. RIWAYAT OBSTETRI : a. Riwayat menstruasi : Menarche : umur.................... ) tidak ( ) Banyaknya : ............................ : ........................... HPHT : ............................ : ...........................

Siklus Lamanya Keluhan

: teratur (

b. Riwayat kehamilan, persalinan, nifas yang lalu : Anak ke Kehamilan PersalinanNo Tahun Umur kehamilan Penyulit Jenis Penolong Penyulit Laserasi

Komplikasi nifasInfeksi Perdarahan Jenis

AnakBB 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 ibu : ........................................................................ Pengobatan didapat : ...................................................................................... Riwayat penyakit keluarga ( ) Penyakit Diabetes Mellitus ( ) Penyakit jantung ( ) Penyakit hipertensi ( ) Penyakit lainnya : sebutkan ......................................................................

dialami yang

4. RIWAYAT LINGKUNGAN : - Kebersihan : ........................................................................................................... ....... - Bahaya : ...................................................................................................................... - Lainnya sebutkan : ................................................................................. ..................... 5. ASPEK PSIKOSOSIAL : a. Persepsi ibu tentang keluhan/ penyakit : ................................................................ b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan seharihari ?............ 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 alasan .......................................... Jenis rumah : ................................................................................. Makanan yang tidak disukai/ pantangan : ............................................. b. Pola eliminasi :

nafsu, makanan alergi/

BAK Frekwensi : ....................kali Warna : ....................... . Keluhan saat BAK : ................................................. ......................

BAB 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 Penunjang 1) Laboratorium : ..................................................................................... ............

2) 3) ............ 4)

USG : ................................................................................................. Rontgen : ..................................................................................... Terapi yang didapat : ............................................................................................................ ........................................................................................................................... ........................................................................................................................... ...............

e. Data Tambahan ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... Surabaya, ........................................ Pemeriksa

( Subhan.)