Kamis, 10 September 2009

Format pengkajian 2

FORMAT PENGKAJIAN
GANGGUAN SISTEM REPRODUKSI
UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :

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

B. STATUS KESEHATAN SAAT INI 
1. Alasan kunjungan ke rumah sakit : ....................................................……................
..............................................................................................................................................………………………………………………………………………………………..…
2. Keluhan utama saat ini : ..................................................................……..................
..............................................................................................................................................…………………………………………………………………………………….……
3. Timbulnya keluhan : ( ) bertahap, ( ) mendadak
4. Faktor yang memperberat : ..........................................................…….....................
.............................................................................................................…...............................…………………………………………………………………………………..…….
5. Upaya yang dilakukan untuk mengatasi : ................................…….........................
............................................................................................................................................…………………………………………………………………………………………...
6. 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 Tahun Umur kehamilan Penyulit 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 Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat: .............................................................................................................................................................................................................................................................................................................................................................................

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

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