PENGKAJIAN PASIEN DI RUANG HEMODIALISA

PROGRAM STUDI PROFESI NERS STIKES dr.

SOEBANDI JEMBER

Nama Mahasiswa :Thariq Faisal Badri., S. Kep. Tempat Praktik

: NIM :19020090 Tgl. Praktik
:

A. IDENTITAS
Nama : ...........................................................................................
Umur : ...........................................................................................
Status : ...........................................................................................
Agama : ...........................................................................................
Tanggal masuk : ...........................................................................................
Tanggal pengkajian : ...........................................................................................
Sumber informasi : ...........................................................................................

B. PENGKAJIAN KEPERAWATAN
1. Keluhan Utama : ..........................................................................................
: ..........................................................................................
2. Diagnosa Medis :
3. Dialiasis Ke :
4. BB Kering :

Interval dengan HD HbsAg Negatif, Positif

Sebelumnya
Sifat HD Akut, Kronis,
Preparation
Golongan Darah A, B, O, AB

5. Riwayat Alergi Obat :

6. Nyeri (Vas Scale):

Durasi Nyeri : Akut/ Kronik

Ringan: 1-3, Sedang: 4-6, Berat: 7-10

7. Riwayat Penyakit Sekarang :..............................................................................................

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8. Riwayat Penyakit Dahulu : ...........................................................................................
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9. Resiko Jatuh
Resiko Jatuh (Morse Scale) √ Skor
(Cheklist)

Riwayat Jatuh
pada kotak yang baru atau dalam 3
skor Tidak 0=
bulan
Ya 25=
Diagnosis
Terakhir medis sekunder >1 Tidak 0=
Ya 15 =
Alat bantu jalan Bed rest 0=
Penompang tongkat 15=
Furnitur 30=
Memakai terapi heparin lock/iv Tidak 0=
Ya 20=
Cara berjalan/ Berpindah Normal/bedrest/imobilisasi 0=
Lemah 10=
Terganggu 20=
Status mental Orientasi sesuai kemampuan 0=
Lupa keterbatasan 15=
Kesimpulan : 0-24 (tidak berisiko), >24-45 (risiko sedang), >45 (risiko tinggi)
Skor Total:.........................................................................................................................

10. Pemeriksaan Fisik

Keadaan Umum :

TD : mmHg RR : x/menit

N : x/menit S : OC
 BB/ TB: kg/ cm

Kepala:

Leher:

Thoraks:

Abdomen:

Inguinal:
 Ekstremitas:

11. Pemeriksaan Laboratorium

C. PERSIAPAN
Mesin Dialisa Dializer
Model Normal/ tidak Model
Monitor Normal/ tidak Tes Volume
Konduktivitas Re Use Ya/ Tidak, Ke
Dialisat Acetat/ Bicarbonat

D. PUNKSI
• Arteri :..............................................................................................................
• Vena : .............................................................................................................
• AV Shunt : .............................................................................................................
• Lama tindakan : .............................................................................................................
Pelaksana (Tulis Nama Penyulit
Dokter Jenis Penanganan
Perawat Sukar
Operasi
Plebitis
Hematoma
Infeksi
Mudah

E. DATA
i. Pre HD
TD Anemis, Ronchi, Ascites, Edema
N Lain-lain:
RR
S HB
BB BUN
BB Post HD Creatinin
Kenaikan BB
ii. Durante HD
Jam Mulai Jam Selesai
QB QD
Intake Output
Priming Muntah
Heparinasi Urin
Regional
Heparinasi TMP
Continue
Dosis Awal Ultra Filtrasi
Dalam PZ
Tranfusi/ Infus
Darah
Albumin
Nabic

• Lama HD :

• TMP :

• Balance :

iii. Post HD
TD Anemis, Ronchi, Ascites, Edema
N Lain-lain:
RR
S HB
BB BUN
BB Post HD Creatinin
Kenaikan BB
 ANALISIS DATA KEPERAWATAN

PRE HEMODIALISA
NO DATA MASALAH ETIOLOGI
Intra Hemodialisa

Persiapan Perawat

Persiapan Alat dan Ruang

Alat steril:

Alat tidak steril:

Bahan medis habis pakai:

Persiapan Pasien

Prosedur Hemodialisa
ANALISA DATA SELAMA HEMODIALISA
NO DATA MASALAH ETIOLOGI
Post Hemodialisa
Persiapan Perawat

Persiapan Alat dan Ruang

Alat steril:

Alat tidak steril:

Bahan medis habis pakai:

Ending mesin HD
ANALISIS DATA POST HEMODIALISA
NO DATA MASALAH ETIOLOGI