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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN RESUME KASUS KELOLAAN HARIAN


KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa :
NIM
:
Tempat Pengkajian
Tanggal
:

IDENTITAS KLIEN
Nama
:
Umur
:
Jenis
:
Kelamin
Agama
:
Pendidikan :
Alamat

Diagnosa
Medis

No. RM
Pekerjaan
Status
Perkawinan
Tanggal MRS
Tanggal
Pengkajian
Sumber
Informasi

:
:
:
:
:
:

PENGKAJIAN PRE HEMODIALISA


Keadaan umum:

Keluhan :

..
..

BB :
Status cairan dan elektrolit :

Tanda vital:

PENGKAJIAN INTRA HEMODIALISA


Keluhan :

Data Objektif :
Cairan dialisat :
TMP :
Qd :
Qb :
Dosis Heparin :
Tanda vital:

PENGKAJIAN POST HEMODIALISA


Keadaan umum :

...
Keluhan :

.
......
BB :

Status cairan dan elektrolit :

Tanda vital:

S (Subjektif):
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O (Objektif):
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A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar
DS dan DO):
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P(Perencanaan):
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I (Implementasi):
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E (Evaluasi)
S(Subjektif): .......................................................................................
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O(Objektif): .........................................................................................
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A(Analisa): ..........................................................................................
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P(Perencanaan): ................................................................................
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Jember,
September 2015