Aplikasi Merah Putih

Assalamualaikum.
dalam rangka memeriahkan hari kemerdekaan Indonesia, telah hadir aplikasi merah putih terbaru untuk mendapatkan pulsa gratis. Sudah terbukti dapat pulsa langsung. Sebarkan berita gembira ini. Download aplikasinya lewat link dibawah ini :
https://invite.cashtree.id/fd659d

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

  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

















Hasil pemeriksaan diagnostik lain :






Persepsi Klien terhadap penyakitnya :
___________________________________________________________________________                             

Kesan perawat terhadap klien :
___________________________________________________________________________                              ___________________________________________________________________________



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