ASUHAN KEPERAWATAN HEMODALISA

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 3 Generasi

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
Intake makanan :
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- Pola Istirahat
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 - Pola Aktivitas
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- Pola Eliminasi Uri / Bowel
BAB : ……….x/hr Warna :..……… . Konsistensi : …………….
Produksi Urine : ………….ml…………x/hr
Warna :
- Personal Hygiene
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Tanda – tanda vital :

a. Suhu/T :……………….0C  Axilla  Rektal  Oral
b. Nadi/HR : ………………x/mt
c. Pernapasan/RR : …..…………..x/tm
d. Tekanan Darah/BP : ……...………..mm Hg
e. BB Pre HD : ……………….
Setting Mesin
a. UF Goal : ................ ml
b. UF Rate : ................ /jam
c. Time : ................ jam

D. INTRA HD
1. Suhu/T :……………….0C  Axilla  Rektal  Oral
2. Nadi/HR : ………………x/mt
3. Pernapasan/RR : …..…………..x/tm
4. Tekanan Darah/BP : ……...………..mm Hg
5. Keluhan selama HD :
 6. Nutrisi selama HD
a. Jenis makanan : ...............................................
Jumlah : ................. cc/24 jam
b. Jenis minuman : ...............................................
Jumlah : ................. cc/24 jam

Catatan Observasi Pasien selama Proses Hemodialisa

Paraf
Pasien Mesin Masalah / Tindakan
Petugas
Jam Uf
Res
TD N QB UFG UFR Remove
p
d
E. Post HD
1. Keadaan Umum :
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2. Tanda – tanda Vital
1. Suhu/T : …………….0C  Axilla  Rektal  Oral
2. Nadi/HR : ………………x/mt
3. Pernapasan/RR : …..…………..x/tm
4. Tekanan Darah/BP : ……...………..mm Hg
5. BB Post HD : ......................... kg
6. Jumlah cairan yang dikeluarkan: ............................ ml

F. Perencanaan Pulang (Discharge Planning) :

1. Obat – obatan yang disarankan / Obat Rutin:
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2. Makanan / Minuman yang dianjurkan (jumlah) :
Makanan yang bergizi dengan jumlah secukupnya
Intake makanan : .........................................................................................
Intake cairan : ..............................................................................................
3. Rencana HD / Kontrol selanjutnya :
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4. Catatan lain :
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Data Penunjang
Pemeriksaan yang pernah diakukan dan hasilnya
1) Laboratorium
a) Darah
Tanggal pemeriksa :
Komponen Hasil Nilai Normal Satuan
 ANALISIS DATA

Data Subyektif Dan

Kemungkinan Penyebab Masalah
Data Obyektif
Prioritas Masalah
 Rencana Keperawatan
Nama Pasien :
Ruang Rawat :
Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional
 Rencana Keperawatan
Nama Pasien :
Ruang Rawat :
Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

-
 Implementasi Keperawatan

Nama Pasien:
Ruang Rawat:

Evaluasi (SOAP) Tanda tangan

Hari/Tanggal Implementasi dan
Nama Perawat
 Implementasi Keperawatan

Nama Pasien:
Ruang Rawat:

Evaluasi (SOAP) Tanda tangan

Hari/Tanggal Implementasi dan
Nama Perawat