PENGKAJIAN ASUHAN KEPERAWATAN MATERNITAS PADA WANITA

DENGAN GANGGUAN SISTEM REPRODUKSI

Nama mahasiswa : ………………………………….

Tempat praktek : ………………………………….
Tanggal : ………………………………….

I. Identitas diri Klien

Nama : ………………………………………………………………..
Usia : ………………………………………………………………..
Jenis kelamin : ………………………………………………………………..
Pendidikan : ………………………………………………………………..
Pekerjaan : ………………………………………………………………..
Tanggal masuk RS : ………………………………………………………………..
Sumber Informasi : ………………………………………………………………..
Keluarga terdekat yang dapat segera dihubungi
(orang tua, wali, suami, istri, dll): ……………………………………………………

II. Status kesehatan saat ini

1. Alasan kunjungan/ keluhan utama
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2. Riwayat kesehatan sekarang
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3. Faktor pencentus : ………………………………………………….......
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4. Lamanya keluhan : …………………………………………………………………
5. Timbulnya keluhan : ( ) Bertahap ( ) Mendadak
6. Faktor yang memperberat: ………………………………………………….........
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7. Upaya yang dilakukan untuk mengatasinya :
Sendiri : …………………………………………………………………....
Oleh orang lain : ……………………………………………………………………
8. Diagnosa medik :
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III. Riwayat Keluarga
Genogram
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IV. Riwayat kesehatan yang lalu

1. Penyakit yang pernah dialami
Kanak-kanak : …………………………………………………………………..
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Kecelakaan : …………………………………………………………………..
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Pernah dirawat : …………………………………………………………………..
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Operasi : …………………………………………………………………..
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2. Imunisasi :
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3. Alergi:
Tipe : …………………………………………………………………..
Reaksi : …………………………………………………………………..
Tindakan : …………………………………………………………………..
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Kebiasaan: merokok/kopi/obat/alkohol/lain-lain:
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4. Obat-obatan:
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5. Lamanya: ……………………………………………………………………………..

V. Pemeriksaan Fisik dan Keluhan Fisik yang Dialami

Keadaan Umum:
Kesadaran : ………………………………………………………………………………
Vital sign : TD = ……………………… HR = ………………………
RR = ……………………… T = ………………………
Data Laboratorium
Tanggal dan
Hasil pemeriksaan dan nilai
jenis Interpretasi
normal
pemeriksaan
Analisa Data

Data Kemungkinan Penyebab Masalah

Diagnosa Keperawatan
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Rencana, Implementasi, Evaluasi
Tanggal/ Diagnosa
NOC NIC Implementasi Evaluasi
Jam Keperawatan