A. PENGKAJIAN

I. IDENTITAS PASIEN

Nama : ........................................

Umur : ........................................

Pendidikan : ........................................

Pekerjaan : ........................................

Status perkawinan : .......................................

Agama : .......................................

Suku : .......................................

Alamat : .......................................

No. CM : .......................................

Tanggal MRS : ........................................

Tanggal pengkajian: ........................................

Sumber Informasi : ........................................

Diagnosa masuk : ........................................

PENANGGUNG/ SUAMI

Nama : ........................................

Umur : ........................................

Pendidikan : ........................................

Pekerjaan : ........................................

Alamat : ........................................

Hubungan dengan pasien : ........................................

II. RIWAYAT PENYAKIT

Keluhan utama (saat MRS dan sekarang)

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Riwayat Penyakit Sekarang

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III. RIWAYAT OBSTETRI DAN GINEKOLOGI

a. Riwayat Menstruasi :

Menarche : umur ................. Siklus : teratur ( ) tidak ( )

Banyaknya : ........................... Lamanya : ..............................

Keluhan : ...........................

b. Riwayat Pernikahan :

Menikah : ................. kali Lama : ............... tahun

c. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi Nifas Anak

No TahunUmur

KehamilanPenyulit Jenis Penolong

Penyuli

tLaserasi Infeksi

Perdaraha

n

Jenis

KelaminBB Pj

d. Riwayat Keluarga Berencana :

Akseptor KB : jenis ..................... Lama : .........................

Masalah : .............................

e. Riwayat Penyakit Klien dan Keluarga

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IV. POLA FUNGSIONAL KESEHATAN

a. Pemeliharaan dan persepsi terhadap kesehatan

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b. Nutrisi/ metabolic

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c. Pola eliminasi

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d. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4

Makan/minum

Mandi

Toileting

Berpakaian

Mobilisasi di tempat tidur

Berpindah

Ambulasi ROM

0: mandiri, 1: alatbantu, 2: dibantu orang lain, 3: dibantu orang lain danalat, 4:

tergantung total

Keterangan :

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e. Pola tidur dan istirahat

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f. Pola perseptual

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g. Pola persepsi diri

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h. Pola seksual dan reproduksi

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i. Pola peran-hubungan

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j. Pola manajemen koping stress

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k. Sistem nilai dan keyakinan

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V. PEMERIKSAAN FISIK

Keadaan Umum

GCS : .........................................................................................................

Tingkat Kesadaran : .........................................................................................................

Tanda-tanda vital : TD ............... N ................. RR .......................... T...................

BB : ..................... TB ................ LILA : ......................

Head to toe

Kepala wajah :

Mata :

Leher :

Dada :

Payudara Inspeksi :

Areola ................. Puting : (menonjol/tidak)

Tanda dimpling/retraksi : ....................................

Palpasi : Pengeluaran ASI ...................... Adanya nodul : ...........................

Jantung dan Paru :

Inspeksi: ..........................................................................................................................

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Palpasi: ............................................................................................................................

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Perkusi: ..........................................................................................................................

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Auskultasi: ......................................................................................................................

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Abdomen :

Inspeksi: ..........................................................................................................................

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Auskultasi: ......................................................................................................................

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Palpasi: ...........................................................................................................................

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Perkusi:

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Genetalia dan Perineum :

Kebersihan : ..........................................................................................

Keputihan : ...........................................................................................

Hemoroid : ...........................................................................................

Perdarahan : ...........................................................................................

Karakteristik : ............................................................................................

Ekstremitas :

Atas dan bawah (hasil dibuat terpisah)

(oedema, varises, CRT, kekuatan otot, tonus)

VI. DATA PENUNJANG

a. Data laboratorium yang berhubungan

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b. Pemeriksaan Radiologi

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VII. DIAGNOSA MEDIS

VIII. PENGOBATAN