FORMAT ASUHAN KEPERAWATAN

RUANG HEMODIALISA

Nama Mahasiswa : ..................................................................................

NIM : ..................................................................................
Ruang Praktek : ..................................................................................
Tanggal Praktek : ..................................................................................
Tanggal & Jam Pengkajian : ..................................................................................

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ............................................................................................
Umur : ............................................................................................
Jenis Kelamin : ............................................................................................
Suku/Bangsa : ............................................................................................
Agama : ............................................................................................
Pekerjaan : ............................................................................................
Pendidikan : ............................................................................................
Status Perkawinan : ............................................................................................
Alamat : ............................................................................................
Tgl MRS : ............................................................................................
Diagnosa Medis : ............................................................................................

B. RIWAYAT KESEHATAN / PERAWATAN PRE HD

1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)

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4. Riwayat Penyakit Keluarga

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GENOGRAM KELUARGA :
C. PEMERIKSAAN FISIK
1. Keadaan Umum :
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2. Kepala
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3. Mata
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4. Leher
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5. Paru
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6. Abdomen
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7. Ekstremitas
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8. Integument
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POLA KEBUTUHAN DASAR
- Pola makan / minum
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- Pola Istirahat
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- Pola Aktivitas
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- Pola Eliminasi Uri / Bowel
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- Personal Hygiene
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Tanda – tanda vital :

a. Suhu /T : ………………. ºC
b. Nadi /HR : ………………. x/mnt
c. Pernapasan /RR : ………………. x/mnt
d. Tekanan Darah /BP : ………………. mmHg
e. BB Pre HD : ………………. Kg

Setting Mesin

f. UF Goal : ………………. l
g. UF Rate : ………………. l/jam
h. Time : ………………. jam
 D. INTRA HD
1. Suhu /T : ………………. ºC
2. Nadi /HR : ………………. x/mnt
3. Pernapasan /RR : ………………. x/mnt
4. Tekanan Darah /BP : ………………. mmHg
5. Keluhan selama HD : ………………………………………………………………
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6. Nutrisi selama HD
a. Jenis makanan :
Jumlah :
b. Jenis minuman :
Jumlah :

Catatan Observasi Pasien selama Proses Hemodialisa

Out-
Observasi

Intake (cc) Put (cc) Paraf &

UF Keterangan Nama
Jam QB Tek.Drh
Pulse Resp
(ml/mnt) Rate (mmHg) Lain Jelas
(ml) NaCl Dexrose Makann Lain- UF UF
0,9% 40% /minum lain Removed Volume
PRE- HD
INTRA HD
POST HD

Jumlah : Balance:

Total UF : .........................................ml
E. Post HD
1. Keadaan Umum :
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2. Tanda – tanda Vital
a. Suhu / T : ......................................................................
b. Nadi/HR : ......................................................................
c. Pernapasan : ......................................................................
d. Tekanan Darah : ......................................................................
e. BB Post HD : ......................................................................
f. Jumlah cairan yang dikeluarkan : ......................................................................

F. Perencanaan Pulang (Discharge Planning) :

1. Obat – obatan yang disarankan / Obat Rutin:
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2. Makanan / Minuman yang dianjurkan (jumlah) :
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3. Rencana HD / Kontrol selanjutnya :
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4. Catatan lain :
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Data Penunjang
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