FORMAT PENGKAJIAN GINEKOLOGI

Nama Mahasiswa :

Nomor Mahasiswa :

Tempat Praktek :

Tanggal Praktek :

I.Identitas diri klien

Nama Klien :

Tempat Tgl Lahir ;

Umur Klien :

Jenis Kelamin :

Alamat :

Status Perkawinan :

Agama :

Suku :

Pendidikan :

Pekerjaan :

Tanggal MRS :

NO. RM :

Tanggal Pengkajian :

Sumber informasi :

Keluarga yang dapat dihubungi :

Pendidikan :

Pekerjaan :

Alamat :

II. Status Kesehatan Saat ini

1.Keluhan Utama Saat Ini :

___________________________________________________________________________

2. Faktor pencetus :

_________________________________________________________________________

___________________________________________________________________________

3. lamanya keluhan :

__________________________________________________________________________

4. Timbulnya keluhan :

__________________________________________________________________________

5. Faktor yang memperberat :

___________________________________________________________________________

6. Upaya yang dilakukan untuk mengatasinya :

Sendiri : __________________________________________________________________

___________________________________________________________________________

Oleh orang lain : ___________________________________________________________

___________________________________________________________________________

Diagnosa Medik : ____________________________________________________________

___________________________________________________________________________

Kesehatan Reproduksi : Kehamilan G P A

No. Anak	Gg. Kehamil an	Proses Persalin an	Lama Persalin an	Tempat Persalin an	Masa Lah per Salin an	Masalah Nifas Dan laktasi	Masalah bayi	Keadaa An anak Saat ini

Pemeriksaan payudara:______________________________________________________

keluhan payudara : ________________________________________________

Pemeriksaan Genetalia : _____________________________________________________

keluhan genetalia :_________________________________________________

Usia menarche : ___________________________________________________________

Usia perkawainan__________________________________________________________

Siklus menstruasi __________________________________________________________

Karakteristik menstruasi ; ___________________________________________

Menopause_______________________________________________________________

,keluhan yang muncul selama ini _____________________________________

Masalah yang berhubungan dengan kesehatan reproduksi : _________________________

o sejak kapan ______________________________________________________

o sudah dilakukan _________________________________________________

Penbedahan_______________________________________________________________

________________________________________________________________________

Pemeriksaan papsmear terakhir________________________________________________

________________________________________________________________________ .

Pemeriksaan payudara sendiri ; _______________________________________________

________________________________________________________________________

III. Riwayat Kesehatan Yang Lalu

Penyakit yang pernah dialami :

Kanak – kanak : __________________________________________________
Kecelakaan :____________________________________________________
Pernah dirawat ___________________________________________________

Alergi ________________________________________________________________
Imunisasi : ____________________________________________________________
Kebiasaan merokok,kopi,obat dan alcohol _____________________________________

_____________________________________________________________________

Obat-obatan :___________________________________________________________

_____________________________________________________________________

Pola Nutrisi :

______________________________________________________________________

________________________________________________________________________

___

Pola eliminasi :

Buang Air Besar

_______________________________________________________________

Buang Air kecil

__________________________________________________________________

Pola Todur dan Istirahat

_____________________________________________________________________

Pola Aktifitas dan Latihan

_____________________________________________________________________

Pola bekerja

_____________________________________________________________________

IV. Riwayat Keluarga

Genogram

Riwayat Lingkungan: __________________________________________________________

___________________________________________________________________________

Aspek psikososial :

Pola pikir dan persepsi:

_____________________________________________________________________

Persepsi diri

_____________________________________________________________________

Suasana hati

_____________________________________________________________________

Hubungan/komunikasi

____________________________________________________________________ ]

_____________________________________________________________________

Kebiasaan Seksual

_____________________________________________________________________

Pertahanan koping

_____________________________________________________________________

Sistem Nilai dan kepercayaan

_____________________________________________________________________

Tingkat perkembangan

_____________________________________________________________________

VII. Pengkajian Fisik

Tanda Vital : Tekanan darah : ________ mmHg

Nadi : __________- x/m

Temperatur : __________ ‘C

Respirasi rate : _________ x/m

Berat Badan : _____ kg , Tinggi Badan : _______ cm

Kepala : ____________________________________________________________________

___________________________________________________________________________

Mata :______________________________________________________________________

___________________________________________________________________________

Hidung : ___________________________________________________________________

___________________________________________________________________________

Mulut dan Tenggorok : ________________________________________________________

____________________________________________________________________

Pernafasan : _________________________________________________________________ __________________________________________________________________

Sirkulasi : __________________________________________________________________

___________________________________________________________________________

Nutrisi : ____________________________________________________________________

Eliminasi : __________________________________________________________________ __________________________________________________________________

Genetalia : __________________________________________________________________

Neurosis : __________________________________________________________________ __________________________________________________________________

Muskuloskeletal : ____________________________________________________________

Kulit : _____________________________________________________________________ .

Data Laboratorium

Tanggal dan jenis pemeriksaan	Hasil pemeriksaan dan nilai normal	Interpretasi

Terapi Medis yang diberikan

Tanggal	Jenis terapi	Rute terapi	Dosis	Indikasi terapi

Hasil pemeriksaan diagnostik lain :

Persepsi Klien terhadap penyakitnya :

___________________________________________________________________________

Kesan perawat terhadap klien :

___________________________________________________________________________ ___________________________________________________________________________

MULTI INFO

FORMAT PENGKAJIAN GINEKOLOGI

No comments:

Blog Archive