FORMAT PENGKAJIAN GINEKOLOGI | Kumpulan Asuhan Keperawatan

FORMAT PENGKAJIAN GINEKOLOGI

March 7th, 2012 0 Comments

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PREVIEW VIDEO ISI DVD KEPERAWATAN

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Nama Mahasiswa&nbsp     : 
Nomor Mahasiswa       :
Tempat Praktek           :
Tanggal Praktek          :
 


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.
Gg.
Kehamil
an
Persalin
an
Lama
Persalin
an
Tempat
Persalin
an
Lah per
Salin
an
laktasi
Masalah
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
  1. Penyakit yang pernah dialami :
    1. Kanak – kanak : __________________________________________________
    2. Kecelakaan    :____________________________________________________
    3. Pernah dirawat ___________________________________________________
  2. Alergi ________________________________________________________________  
  3. Imunisasi : ____________________________________________________________
  4. Kebiasaan merokok,kopi,obat dan alcohol _____________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Obat-obatan :___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Pola Nutrisi :
     ______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___
  1. Pola eliminasi :
    1. Buang Air Besar
_______________________________________________________________
_______________________________________________________________
    1. Buang Air kecil
__________________________________________________________________
__________________________________________________________________
  1. Pola Todur dan Istirahat
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Pola Aktifitas dan Latihan
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Pola bekerja
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
IV. Riwayat Keluarga
Genogram
 
                         
                 
Riwayat Lingkungan: __________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Aspek psikososial :
  1. Pola pikir dan persepsi:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Persepsi diri
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Suasana hati
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Hubungan/komunikasi
____________________________________________________________________ ]
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. Kebiasaan Seksual
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  
  1. Pertahanan koping
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
 
  1. Sistem Nilai dan kepercayaan
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
  1. 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
Persepsi Klien terhadap penyakitnya :
___________________________________________________________________________                             
Kesan perawat terhadap klien :
___________________________________________________________________________                              ___________________________________________________________________________

Artikel:

format pengkajian keperawatan ginekologi, gsr ginekologi
 

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