FORMAT PENGKAJIAN KEPERAWATAN

RESUME KEPERAWATAN MEDIKAL BEDAH

HEMODIALISA

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

IDENTITAS KLIEN
Nama : No. RM :
Umur : Pekerjaan :
Jenis Kelamin : Status Perkawinan :
Agama : Tanggal MRS :
Pendidikan : Tanggal Pengkajian :
Alamat : Sumber Informasi :
Diagnosa :
Medis

PROSES KEPERAWATAN
Perjalan Penyakit Pasien
(Awal Pasien terdiagnosis CKD hingga pasien di instruksikan hemodialisis)
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PRE HEMODIALISA
1) Data Fokus
Data Subjektif:
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Data Objektif:
BB Pre HD : Kg
BB post HD sebelumnya : Kg
Peningkatan BB interdialisis : Kg
Tanda vital :
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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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INTRA HEMODIALISA
1) Data Fokus
Data Subjektif:
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Data Objektif:
UF Goal :
Cairan dialisat :
TMP :
Qd :
Qb :
Dosis Heparin :
Tanda vital :
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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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POST HEMODIALISA
1) Data Fokus
Data Subjektif:
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Data Objektif :
BB Post HD :
Tanda vital :
Pengkajian Akses HD :
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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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