STIKES BALI

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

DENGAN ................................................................................
DI RUANG ................................. RSUP .............................................
TANGGAL ..............................................................

A. PENGKAJIAN
Pengkajian dilakukan pada hari................................................ pukul ......................... wita di
Ruang ................................ RSUP ......................................... dengan tehnik wawancara, observasi,
pemeriksaan fisik dan catatan keperawatan (Rekam Medis).

1. PENGUMPULAN DATA
a. Data Umum Pasien
Pasien Penanggung
Nama Pasien : ............................. Nama : ................................
Usia : ............................. Usia : ................................
Jenis Kelamin : ............................. Jenis Kelamin : ................................
Status Perkawinan : ............................. Status Perkawinan : ................................
Agama : ............................. Agama : ................................
Suku Bangsa : ............................. Suku Bangsa : ................................
Pendidikan terakhir : ............................. Pendidikan terakhir : ................................
Pekerjaan : ............................. Pekerjaan : ................................
Alamat : ............................. Alamat : .............................

No. Register : .............................

Tanggal MRS : .............................

b. Data Umum Kesehatan saat ini

1) Keluhan utama (saat MRS dan pengkajian)
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 STIKES BALI

2) Riwayat Penyakit (Riwayat hemodialisa sebelumnya)

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 STIKES BALI

3) Riwayat Penyakit Sebelumnya :

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4) Riwayat Penyakit Keluarga

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c. Pola Kebiasaan ( Biologis , Psikologis, Sosial, Spiritual)

1) Biologis
a) Bernafas
Sebelum pengkajian :
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Saat pengkajian :
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b) Makan
Sebelum pengkajian :
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Saat pengkajian :
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c) Minum
Sebelum pengkajian :
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Saat pengkajian :
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 STIKES BALI

d) Eleminasi
Sebelum pengkajian :
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Saat pengkajian :
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e) Gerak dan Aktivitas

Sebelum pengkajian :
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Saat pengkajian :

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f) Istirahat dan tidur

Sebelum pengkajian :
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Saat pengkajian :
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g) Pengaturan Suhu Tubuh
Sebelum pengkajian :
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Saat pengkajian :
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h) Kebersihan diri
Sebelum pengkajian :
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Saat pengkajian :
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i) Rasa Nyaman
Sebelum pengkajian :
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Saat pengkajian :
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j) Rasa aman
Sebelum pengkajian :
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Saat pengkajian :
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k) Bekerja / Produktivitas
Sebelum pengkajian :
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Saat pengkajian :
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l) Rekreasi
Sebelum pengkajian :
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Saat pengkajian :
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m) Belajar
Sebelum pengkajian :
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Saat pengkajian :
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n) Data sosial
Sebelum pengkajian :
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Saat pengkajian :
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o) Ibadah
Sebelum pengkajian :
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Saat pengkajian :
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 STIKES BALI

d. Pemeriksaan Fisik
1) Keadaan Umum
a) Keadaan Umum : ..........................
b) Kesadaran : GCS = ............ ( E....... , M......., V........)
(.............................................................)
c) Bangun Tubuh : ..........................
d) Postur Tubuh : ..........................
e) Cara Berjalan : ..........................
f) Gerak Motorik : ..........................
g) Keadaan Kulit :
 Warna Kulit : ..........................
 Turgor Kulit : ..........................
 Kebersihan : ..........................
 Akral Kulit : ..........................
 Kelembaban : ..........................
 Tesktur : ..........................
 CRT : ..........................
 Luka : ...............................................................................................
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 Temuan Lain : ...............................................................................................
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h) Tanda-Tanda Vital : Suhu : .................... oC

Denyutan Nadi : .................... x / menit
Respirasi Rate : .................... x / menit
Tekanan Darah : .................... mmHg
i) Ukuran lain :
Post-Hemodialisa
Pengukuran Berat Badan Kering Pre-Hemodialisa
( ........................... )
Berat Badan

Tinggi Badan
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2) Pemeriksaan Head to Toe

a) Kepala / Wajah
Inspeksi :
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Palpasi :
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b) Mata
Inspeksi :
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Palpasi :
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Dengan Alat : ( .................................................... )
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c) Hidung
Inspeksi :
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Palpasi :
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d) Mulut
Inspeksi :
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Palpasi :
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 STIKES BALI

e) Telinga
Inspeksi :
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Palpasi :
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Dengan Alat : ( .......................................................... )
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f) Leher
Inspeksi :
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Palpasi :
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g) Dada
 Ketiak / Axilla
Inspeksi : ...........................................................................................................
Palpasi : ...........................................................................................................

 Payudara
Inspeksi : ...........................................................................................................
Palpasi : ...........................................................................................................
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 Jantung
Inspeksi : ...........................................................................................................
Palpasi : ...........................................................................................................
Perkusi : ...........................................................................................................
Auskultasi : ...........................................................................................................

 Paru – Paru
Inspeksi : ...........................................................................................................
Palpasi : ...........................................................................................................
 Perkusi : ...........................................................................................................
Auskultasi : ..........................................................................................................

Temuan lain di Daerah Dada :

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h) Abdomen
Inspeksi :
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Auskultasi :
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Perkusi :
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Palpasi :
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Temuan lain di daerah abdomen :
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i) Genitalia
Inspeksi :
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Palpasi :
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 STIKES BALI

j) Anus
Inspeksi :
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Palpasi :
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k) Ekstremitas
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Infus

Akral Hangat

Edema

Varises

Sianosis

Clubing finger

Kekuatan otot

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