PROGRAM PROFESI NERS

FAKULTAS ILMU-ILMU KESEHATAN

UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN”
JAKARTA

PENGKAJIAN KEPERAWATAN DI RUANG HEMODIALISIS

Nama Mahasiswa : Kelompok 3 Semester/Tingkat : II

Tempat Praktek : Ruang HD RSUD PM Tanggal Pengkajian : 25 Juni 2018

DATA KLIEN

DATA UMUM
1. Nama inisial klien : NY. H Umur : 59 Tahun

2. Agama : Islam Tanggal masuk RS : 25 Juni 2018

3. Nomor Rekam Medis : 071261 Diagnosa medis : CKD ON HD

DATA PRE HD

Keluhan :
Klien mengatakan badannya lemas, klien mengatakan berat badan hari ini 52 Kg

A. PEMERIKSAAN FISIK
a) Vital sign
TD : 130/80 mmHg Nadi : 65 x/menit P: 20 x/menit Suhu : 366 ˚C
b) Respiratory : ○Normal ○Dispnoe ○Ronchi ○Wheezing
c) Edema : ○Tidak ada ○Etrimitas ○Wajah ○Asites
d) Data berat badan : BB kering: 52 kg BB Pra : 52 kg
e) Tipe akses vaskuler : ○AV Fistula ○Femoralis ○Double lumen
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PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ

3. SKALA NYERI

Nyeri : ○Tidak ○Ya

○Nyeri kronis, Lokasi :………….. Frekuensi :………… Durasi :……………

○Nyeri Akut, Lokasi :………….. Frekuensi :………… Durasi :……………

○Score nyeri (0-10) :…………....... Karakteristik Nyeri : ..........................................

Nyeri hilang

○Minum obat ○Istirahat ○Mendengar musik ○Berubah posisi tidur

○Lain-lain, sebutkan : Tidak Ada

4. CAIRAN DAN ELIMINASI:

a. Cairan masuk: Minum: 800 cc, Parenteral: .......................................
b. Pengeluaran:
c. Urine:
1) Pola pembuangan urine (frekuensi, jumlah, ketidaknyamanan) : 3-4 x/Hari (200cc)
2) Riwayat kelainan kandung kemih : Tidak Ada
3) Pola urine (jumlah, warna, kekentalan, bau) : 200 cc, Kuning pekat, Tidak berbau
4) Distensi kandung kemih/retensi urine : Tidak ada

Total balance input-output: IWL = 15 X 52/24 = 32,5 cc

100 – 1200 + 32,5 = 100 – 232,5 = -132,5 cc

5. DATA DIALIZER

Luas membrane : 1,5 m2 ○Low Flux ○High Flux

Jenis dialyzer : ○Baru ○Reuse,ke 3 /volume priming: 1500 ml

Hasil tes sisa renalin (khusus dialyzer reuse) : ○ 0 ○1 ○3

Parameter mesin : Alarm test:○Tidak ○Ya, conductivity: 500 Suhu mesin: 37 ˚C

Anticoagulan : Tipe : ○ Continue ○Free Heparine

Dosis awal : 2000 unit Dosis pemeliharaan: 750 unit//jam Total: 4250 unit
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PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ

B. PEMERIKSAAN PENUNJANG:

Hasil Lab :
HEMATOLOGI
Hemoglobin : 9.7 g/dL
Hematokrit : 29 %
Leukosit : 10.9 103/uL
Trombosit : 276 103/uL
Eritrosit : 3.06 106/uL

C. DATA TAMBAHAN:

Tidak Ada

D. MASALAH KEPERAWATAN:
1) ................................................................................................................................................

2) ................................................................................................................................................

3) ................................................................................................................................................

4) Dst..........................................................................................................................................

E. INTERVENSI/IMPLEMENTASI:
1. ................................................................................................................................................
2. ...............................................................................................................................................
3. ................................................................................................................................................
4. ................................................................................................................................................
5. ................................................................................................................................................
6. Dst..........................................................................................................................................

F. EVALUASI:

S:

O:
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A:

PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ

P:

DATA INTRA HD:

A. OBSERVASI PROGRAM DIALISIS:

Jam PASIEN Mesin

TD Nadi QB Vena UF UF UF
pressure Goal Rate Removed
10:30 130/80 65 230 87 500 625 0
11:30 110/70 73 230 114 500 625 125
12:30 140/80 86 230 131 500 625 340
13:30 130/80 76 230 122 500 625 500

B. PEMERIKSAAN PENUNJANG:

Tidak Ada

C. DATA TAMBAHAN:
Tidak Ada

D. MASALAH KEPERAWATAN:
1) ...............................................................................................................................................

2) ................................................................................................................................................

3) ................................................................................................................................................
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4) Dst..........................................................................................................................................

PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ

E. INTERVENSI/IMPLEMENTASI:
1) ................................................................................................................................................
2) ...............................................................................................................................................
3) ................................................................................................................................................
4) ................................................................................................................................................
5) ................................................................................................................................................
6) Dst..........................................................................................................................................

G. EVALUASI:

S:

O:

A:

P:

DATA POST HD:

A. Keluhan : Klien Mengatakan Lemas

B. Keadaan umum : Klien Tampak Lemah

C. Tanda-Tanda Vital:
TD : 120/80 mmHg Nadi : 76 x/menit P: 20 x/menit Suhu: 37 ˚C BB-Post: 52 Kg

D. Cairan yang masuk selama HD

Sisa Priming : 60 ml Dializer (single use)
Transfusi : - ml
Wash out : 60 ml
Minum : 50 ml
Jumlah : 170 ml

E. PEMERIKSAAN PENUNJANG:
Tidak Ada
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PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ

F. DATA TAMBAHAN:
Tidak Ada

G. MASALAH KEPERAWATAN:
1) ...............................................................................................................................................

2) ................................................................................................................................................

3) ................................................................................................................................................

4) Dst..........................................................................................................................................

F. INTERVENSI/IMPLEMENTASI:
1) ................................................................................................................................................
2) ...............................................................................................................................................
3) ................................................................................................................................................
4) ................................................................................................................................................
5) ................................................................................................................................................
6) Dst..........................................................................................................................................

H. EVALUASI:

S:

O:

A:

P:
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PRAKTEK KLINIK PROFESI KEPERWATAN GAWAT GARURAT UPNVJ