Format Pengkajian Ginekologi

KEPERAWATAN MATERNITAS PROGRAM STUDI ILMU KEPERAWATAN SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU

PANDUAN PENGKAJIAN GINEKOLOGI

Tgl Pengkajian

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Identitas Klien  Nama Pasien

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Umur

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Agama

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Status Marital

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Pekerjaan

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Suku Bangsa

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Pendidikan

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Alamat

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Diagnosa Medis

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Keluhan Utama

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Riwayat Penyakit Sekarang ............................................ .................................................................. ............................................ ............................................ ............................................ .................................. ............ ............................................ .................................................................. ............................................ ............................................ .............................................. .................................. .......... ........................................... ................................................................. ............................................ ............................................ ............................................ ................................... ............. ............................................ .................................................................. ............................................ ............................................ .............................................. .................................. .......... ............................................ .................................................................. ............................................ ............................................ .............................................. .................................. .......... ............................................ .................................................................. ............................................ ............................................ .............................................. .................................. ..........

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Riwayat kesehatan lalu

................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Riwayat Kesehatan Keluarga ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Pola Pemenuhan Kebutuhan Dasar 

Istirahat ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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 Nutrisi ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Eliminasi ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Ambulasi ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Kebersihan diri ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Lain-lain ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Pemeriksaan Fisik Keadaan Umum

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Tanda-tanda Vital ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Kepala ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Muka ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Leher ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Dada ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Jantung ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

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Paru-paru ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Payudara ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................