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    Lily Permatasari
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    Laporan praktik profesi di instalasi hemodialisa mengenai pengkajian pasien dengan nama dan umur tertentu yang diderita gagal ginjal kronis dan telah menjalani hemodialisa rutin. Pengkajian meliputi identitas pasien, keluhan utama, riwayat penyakit saat ini dan terdahulu, riwayat keluarga, riwayat dialisis, dan pemeriksaan fisik khususnya sistem kardiovaskuler dan respirasi.

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    format resume asuhan pada pasien hemodialisis

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    Format resume HD

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    Laporan praktik profesi di instalasi hemodialisa mengenai pengkajian pasien dengan nama dan umur tertentu yang diderita gagal ginjal kronis dan telah menjalani hemodialisa rutin. Pengkajian meliputi identitas pasien, keluhan utama, riwayat penyakit saat ini dan terdahulu, riwayat keluarga, riwayat dialisis, dan pemeriksaan fisik khususnya sistem kardiovaskuler dan respirasi.

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    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    14 tayangan10 halaman

    Format Resume HD

    Diunggah oleh

    Lily Permatasari
    Laporan praktik profesi di instalasi hemodialisa mengenai pengkajian pasien dengan nama dan umur tertentu yang diderita gagal ginjal kronis dan telah menjalani hemodialisa rutin. Pengkajian meliputi identitas pasien, keluhan utama, riwayat penyakit saat ini dan terdahulu, riwayat keluarga, riwayat dialisis, dan pemeriksaan fisik khususnya sistem kardiovaskuler dan respirasi.

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    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 10

    LAPORAN PRAKTIK PROFESI DI INSTALASI HEMODIALISA

    Resume ………………………………………………………………………
    Nama mahasiswa : …………………………………………………….
    Tanggal praktik : …………………………………………………….

    Nama klien : ……………………………………………………


    Umur/Jenis Kelamin : …………/……………………………………….
    A. Pengkajian

    1. Identitas pasien

     Nama : …………………………………………………….
     No RM : …………………………………………………….
     Umur : …………………………………………………….
     Jenis Kelamin : …………………………………………………….
     Pendidikan : …………………………………………………….
     Pekerjaan : …………………………………………………….
     Dx Medis : …………………………………………………….
     Mula inisiasi HD : …………………………………………………….
    2. Keluhan utama :
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    ….........................................................................................................................................
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    3. Riwayat penyakti sekarang :
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    4. Riwayat penyakit terdahulu :
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    5. Riwayat keluarga :
    .............................................................................................................................................
    ….........................................................................................................................................
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    6. Riwayat Dialisis
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    7. Pemeriksaan Fisik (Data fokus keperawatan HD)
    Keadaan umum : ………………………………………………………………………….

     Sistem Kardiovaskuler :
    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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     Sistem Respirasi :
    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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     Sistem Neurologi :
    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 :
     Sistem Gastrointestinal :
    Mulut  Bersih  Kotor  Berbau
    Mukosa  Lembab  Kering  Stomatitis
    Pembesaran hepar  Ya  Tidak
    Abdomen  Meteorismus  Asites  Nyeri tekan
    Peristaltik: x/mnt
     Sistem Urinaria :
    Penggunaan alat bantu/ kateter  Ya  Tidak
    Kandung kencing, nyeri tekan  Ya  Tidak
    Gangguan  Anuria  Oliguria
     Retensi Inkontinensia
     Nokturia  Lain-lain:
     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 :

    8. Data Hemodialisa
     BB kering : …………………………………………………….
     BB Pra HD : …………………………………………………….
     Tipe Akses vaskuler : …………………………………………………….
     Frekuensi HD : …………………………………………………….
     Lama HD : …………………………………………………….
     Jenis cairan dialisat : …………………………………………………….
     Metode heparinisasi : …………………………………………………….
     Dosis heparin : …………………………………………………….
     Jenis dialiser / vol priming : …………………………………………………….
    o Nilai conductivity/Temp: …………………………………………………….
    9. Data Laboratorium
    …………………………………………………….

    Nilai
    Hari/tanggal Parameter Satuan Hasil Intepretasi
    rujukan

    B. Diagnosa Keperawatan
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    C. Perencanaan
    Rencana Keperawatan
    No
    Hari/tgl
    Dx Tujuan dan kriteria hasil Intervensi Rasional

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    D. Pelaksanaan Implementasi
    No
    Hari/tgl Jam Tindakan keperawatan Respon klien TTD
    Dx
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    E. Evaluasi
    No Hari/Tgl No Dx Jam Evaluasi Ttd

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