PELATIHAN HEMODIALISA

INSTALASI PELAYANAN DIALISIS

RSUP SANGLAH DENPASAR
TAHUN 2014

LAPORAN ASUHAN KEPERAWATAN PADA KLIEN ...............

DENGAN.....................................................................................
DI INSTALASI PELAYANAN DIALISIS RSUP SANGLAH DENPASAR
TANGGAL .......................

A. Pengkajian
1. Identitas
 Pasien
 Nama : ........................................
 Umur : ........................................
 Jenis kelamin : ........................................
 Pendidikan : ........................................
 Pekerjaan : ........................................
 Status perkawinan : ........................................
 Agama : ........................................
 Suku : ........................................
 Alamat : ........................................
 Tanggal masuk : ........................................
 Tanggal pengkajian : ........................................
 Sumber Informasi : ........................................
 Diagnosa masuk : ........................................
 Penanggung
 Nama : ........................................
 Hubungan dengan pasien : ........................................

2. Status kesehatan
a. Status Kesehatan Saat Ini
 Keluhan utama (saat MRS dan saat ini): ...........................................
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 Alasan masuk rumah sakit dan perjalanan penyakit saat

ini: .....................................................................................................
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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

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 Upaya yang dilakukan untuk mengatasinya: ....................................

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b. Status Kesehatan Masa Lalu

 Penyakit yang pernah dialami: ..........................................................
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 Pernah dirawat: .................................................................................

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 Riwayat alergi :  Ya  Tidak

Jelaskan: ............................................................................................
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 Riwayat tranfusi:  Ya  Tidak

 Kebiasaan:
 Merokok:  Ya  Tidak
Sejak: ................................. Jumlah: ..............................................
 Minum kopi  Ya  Tidak
Sejak: ................................ Jumlah: ...............................................
 Penggunaan Alkohol  Ya  Tidak
Sejak: ............................... Jumlah: .............................................
 Lain-lain: ........................................................................................
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 Jelaskan: .....................................................................................
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3. Riwayat Penyakit Keluarga: ..........................................................................

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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

(genogram)

4. Riwayat/ data dialisis

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5. Diagnosa Medis dan terapi: ..........................................................................

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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

6. Pola Fungsi Kesehatan

a. Pemeliharaan dan persepsi terhadap kesehatan: .....................................
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b. Nutrisi/metabolik: ...................................................................................
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c. Pola eliminasi: .........................................................................................
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d. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total.

e. Oksigenasi: ..............................................................................................
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f. Pola tidur dan istirahat: ...........................................................................

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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

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g. Pola kognitif-perseptual: .........................................................................
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h. Pola persepsi diri/konsep diri: .................................................................

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i. Pola seksual dan reproduksi: ...................................................................

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j. Pola peran-hubungan: .............................................................................

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k. Pola manajemen koping stres: ................................................................
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l. Pola keyakinan-nilai: ..............................................................................

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7. Riwayat Kesehatan
Keadaan umum:  Baik  Sedang  Lemah Kesadaran: .................
TTV : TD: Nadi : Suhu: RR:

8. Pemeriksaan Fisik
a. Kulit, Rambut dan Kuku
 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

Distribusi rambut : .......................................................

Lesi:  Ya  Tidak
Warna kulit:  Ikterik  Sianosis  Kemerahan  Pucat
Akral:  Hangat  Panas  Dingin kering  Dingin
Turgor: .........................................................................
Oedem :  Ya  Tidak Lokasi: ..................................
Warna kuku:  Pink  Sianosis  lain-lain
Lain-lain: .......................................................

b. Kepala dan Leher

Kepala:  Simetris  Asimetris
Lesi:  ya  Tidak
Deviasi trakea:  Ya  Tidak
Pembesaran kelenjar tiroid:  Ya  Tidak
Lain-lain: ..........................................................................
c. Mata dan Telinga
Gangguan penglihatan:  Ya  Tidak
Menggunakan kacamata:  Ya  Tidak Visus: ........................
Pupil:  Isokor  Anisokor Ukuran: .....................
Sklera/konjungtiva:  Anemis  Ikterus
Gangguan pendengaran:  Ya  Tidak
Menggunakan alat bantu dengar:  Ya  Tidak
Tes weber: …………. Tes Rinne: ……………. Tes Swabach: …………..
Lain-lain: ..................................................................................................

d. Sistem Pernafasan
Batuk:  Ya  Tidak
Sesak:  Ya  Tidak

 Inspeksi: ..................................................................................................
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 Palpasi: ..................................................................................................
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 Perkusi: ..................................................................................................
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 Auskultasi: ..............................................................................................
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 Lain-lain: .............................................................................................
 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

e. Sistem Kardiovaskular
Nyeri dada:  Ya  Tidak
Palpitasi:  Ya  Tidak
CRT:  < 3 dtk  > 3 dtk
 Inspeksi: ..................................................................................................
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 Palpasi: ....................................................................................................
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 Perkusi: ....................................................................................................
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 Auskultasi: ..............................................................................................
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 Lain-lain: .................................................................................................

f. Payudara Wanita dan Pria

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g. Sistem Gastrointestinal
Mulut:  Bersih  Kotor  Berbau
Mukosa:  Lembab  Kering  Stomatitis
Pembesaran hepar:  Ya  Tidak
Abdomen:  Meteorismus  Ascites  Nyeri tekan
Peristaltik: ……x/menit
Lain-lain : ...................................................................................................

h. Sistem Urinarius
Penggunaan alat bantu/kateter:  Ya  Tidak
Kandung kencing, nyeri tekan:  Ya  Tidak
Gangguan:  Anuria  Oliguria  Retensi  Inkontinensia
 Nokturia  Lain-lain: ..................................................

i. Sistem Reproduksi Wanita/Pria

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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

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j. Sistem Saraf
GCS: Eye: ............. Verbal: ................. Motorik: ......................
Rangsangan meningeal:  Kaku kuduk  Kernig
 Brudzinski I  Brudzinski II

Refleks fisiologis:  Patela  Trisep  Bisep  Achiles

Refleks patologis:  Babinski  Chaddock  Oppenheim
 Rossolimo  Gordon  Schaefer
 Stransky  Gonda
Gerakan involunter: .......................................................................................
Lain-lain: .......................................................................................................

k. Sistem Muskuloskeletal
Kemampuan pergerakan sendi:  Bebas  Terbatas
Deformitas:  Ya  Tidak Lokasi: .......................
Fraktur:  Ya  tidak Lokasi: .......................
Kekakuan:  Ya  Tidak
Nyeri sendi/otot:  Ya  Tidak
Kekuatan otot: ...............................................................................................
Lain-lain: ...................................................................................................

l. Sistem Imun
Perdarahan Gusi:  Ya  Tidak
Perdarahan lama:  Ya  Tidak
Pembengkakan KGB:  Ya  Tidak Lokasi: ...........
Keletihan/kelemahan:  Ya  Tidak
Lain-lain: .......................................................................................................

m.Sistem Endokrin
Hiperglikemia:  Ya  Tidak
Hipoglikemia:  Ya  Tidak
Luka gangren:  Ya  Tidak
Lain-lain: .......................................................................................................
n. Pemeriksaan Penunjang
a. Data laboratorium yang berhubungan: ....................................................
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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

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b. Pemeriksaan Radiologi: ..........................................................................

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c. Hasil Konsultasi: ....................................................................................

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d. Pemeriksaan penunjang diagnostik lain: .................................................
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 PELATIHAN HEMODIALISA
INSTALASI PELAYANAN DIALISIS
RSUP SANGLAH DENPASAR
TAHUN 2014

MENGETAHUI,

PENGUJI, PESERTA
PELATIHAN HD,

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