ASUHAN KEPERAWATAN MEDIKAL PADA PASIEN ....................

DENGAN DIAGNOSA MEDIS...........................................................

DI RUANG.............................................. RSUP SANGLAH
TANGGAL ............................................

A. PENGKAJIAN
Pengkajian pada pasien dilakukan pada tanggal
pukul di Ruang RSUP Sanglah dengan metode
observasi, wawancara, pemeriksaan fisik dan dokumentasi (rekam medis)

1. PENGUMPULAN DATA
a. Identitas Pasien
Pasien Penanggung
()
Nama : .....
Umur : .....
Jenis Kelamin : .....
Status Perkawinan: .....
Suku /Bangsa : .....
Agama : .....
Pendidikan : .....
Pekerjaan : .....
Alamat : .....
Nomor Telepon : .....

Nomor Register : .....

Tanggal MRS : .....
Diagnosa Medis : .

b. Riwayat Kesehatan
1) Keluhan utama MRS
....................................................................................................................
....................................................................................................................
2) Keluhan utama saat pengkajian
.....................................................................................................................
.....................................................................................................................
3) Riwayat penyakit sekarang
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
 .....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
4) Riwayat penyakit sebelumnya
.....................................................................................................................
.....................................................................................................................
5) Riwayat penyakit keluarga
.....................................................................................................................
.....................................................................................................................

c. Pola Kebiasaan (fokus bermasalah)

...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
 ...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
d. Pemeriksaan Fisik (fokus bermasalah)
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
e. Pemeriksaan penunjang
1) Pemeriksaan Laboratorium

Hari/Tanggal/J Jenis
No. Hasil Pemeriksaan Nilai Normal
am Pemeriksaan Lab
2. Analisa Data
Pre HD

Data Subyektif Data Obyektif Interpretasi

Intra Hemodialisa
Data Subyektif Data Obyektif Interpretasi

Post Hemodialisa
 Data Subyektif Data Obyektif Interpretasi

3. Rumusan Masalah Keperawatan

a. Pre Hemodialisa :
b. Intra Hemodialisa :
c. Post Hemodialisa :

4. Diagnosa Keperawatan
a. Pre Hemodialisa :

b. Intra Hemodialisa :
c. Post Hemodialisa :
B. Perencanaan
1. Priritas Masalah
a. Pre Hemodialisa : ..........................................................................................................................................................................................
.........................................................................................................................................................................................................................
.........................................................................................................................................................................................................................
b. Intra Hemodialisa: ..........................................................................................................................................................................................
.........................................................................................................................................................................................................................
.........................................................................................................................................................................................................................
c. Post Hemodialisa :.........................................................................................................................................................................................
.........................................................................................................................................................................................................................
.........................................................................................................................................................................................................................
2. Rencana Perawatan
No Hari/Tgl/ Diagnosa Kep Tujuan & Kriteria Hasil Intervensi
Jam
C. Implementasi
Hari/Tg No Tindakan Keperawatan Evaluasi Paraf
l/Jam DK
Hari/Tg No Tindakan Keperawatan Evaluasi Paraf
l/Jam DK
D. Evaluasi
Hari/Tgl/Jam No. Evaluasi (SOAP)
Dx