Format Resume Keperawatan di Ruangan Hemodialisa

Program Studi Profesi Ners, Jurusan Keperawatan

Poltekkes Kemenkes Pontianak

RESUME PRE HEMODIALISA

1. Tgl & jam pengkajian :........................................................................................................
2. Biodata pasien
Nama :..........................................................................................................................
Umur :..........................................................................................................................
No. RM :..........................................................................................................................
Alamat :..........................................................................................................................
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3. Diagnosa medis : .................................................................................................................
4. Keluhan utama pasien :.........................................................................................................
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5. Data fokus :
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6. Tanda Tanda Vital :
TD:................. mmHg, Suhu:..........0C, Nadi:............ x/menit, Pernafasan:........... x/menit
7. BB sekarang :.........kg
8. BB yang lalu :.........kg
9. BB kering :.........kg
10. Hasil pemeriksaan laboratorium :.......................................................................................
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11. Hasil pemeriksaan lain :.......................................................................................................
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12. Analisis Data
Data Subjektif
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Data Objektif
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13. Diagnosa Keperawatan
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14. Tindakan Keperawatan
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15. Evaluasi Keperawatan
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RESUME INTRA HEMODIALISA
Tgl dan jam pengkajian :
1. Persiapan HD
a. Type Dializer : New/reuse F6/F7/F8
b. Reuse ke : R1/R2/R3/R4/R5/R6/R7
c. Lama Dialisis : 2 jam, 3 jam, 3 1/2 jam, 4 jam, 5 jam
d. Conductivity :
e. Antikoagulan :
1) Inisiasi : 500 U, 1000 U, 2000 U, 3000 U, 4000 U...
2) Kontinyu : 500 U, 1000 U, 1500 U
f. Jenis Acces : CDL/Femoral/AVF/AVG
1) Trill :
2) Redness :
3) Excema :
4) Hematoma :
5) Edema :
g. Total Blood Volume :
h. Waktu SU :
i. UF : ml
2. Data Fokus
a. Data Subyektif :..................................................................................................
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b. Data Obyektif :..................................................................................................
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c. Kesadaran : GCS :
d. Vital Sign :TD: mmHg, Nadi: x/menit, Suhu: 0
C, RR: x/menit.
3. Masalah Keperawatan
a. ........................................................................................................................................
 b. ........................................................................................................................................
c. ........................................................................................................................................
4. Tindakan Keperawatan Selama HD
a. Observasi
Jam Qb Vena TMP UF TD Suhu Nadi UF Keluhan Catatan
Vol

b. Pengobatan selama HD
1) Transfusi darah : kolf, Gol. Darah :
2) Eritropoetin : Hemapo/ Recormon / Epprex :2000 iu /3000 iu / 5000 iu
3) Obat yang diberikan : dosis :
c. Pengawasan cairan selama HD
1) Volume Priming: cc
2) Cairan masuk : cc
3) Sisa Priming : cc
4) Cairan Drip : cc
5) Darah : cc
6) Wash out : cc
Jumlah : cc
d. Penyulit selama HD
1) Shunt problem :
2) Perdarahan :
3) Mual muntah :
4) Kejang :
5) Kram :
6) Panas/Menggigil :
7) Koma :
 8) Sakit dada :
9) Gatal-gatal :
10) Hypotensi :
11) Hypertensi :
12) Alergi Dializer :
5. Evaluasi
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 RESUME POST HEMODIALISA
Tgl & jam pengkajian :
1. Data Fokus
a. Data Subyektif :.......................................................................................
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b. Data Obyektif :.......................................................................................
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c. Kesadaran : GCS :
d. Vital Sign :TD: mmHg, Nadi: x/menit, Suhu: 0
C, RR: x/menit.
e. Lama Dialisis : jam
1) Mulai jam : WIB
2) Selesai : WIB
f. Ultra Filtrasi : Liter
g. Qb : mL/menit
h. Pemberian Heparine
1) Kontinyu : iu
a) Bolus : iu
b) Dosis maintenance : iu/jam
2) Intermitten
a) Bolus : iu
b) Dosis maintenance : iu/jam
3) Minimal Heparine :
a) Bolus : iu
b) Dosis maintenance : iu/jam
4) Free Heparine :
i. Jenis Dializer : F6/F7/F8 N/R
j. Jenis Dialisat :
 k. Jenis akses vaskuler : CDL/femoral/AVF/AVG
l. Pemeriksaan laboratorium:..........................................................................................
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m. Pemeriksaan penunjang lain:.......................................................................................
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n. Tindakan pengobatan selama HD
1) Transfusi darah : ........ kolf, Golongan darah.............
2) Pengobatan saat HD :

2. Diagnosa Keperawatan
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3. Tindakan Keperawatan
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4. Planing
a. HD selanjutnya tanggal :
b. Rencana Lama HD : jam
5. Evaluasi
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 DISCHARGE PLANNING PASIEN HEMODIALISIS
1. Informasi kesehatan
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2. Edukasi kesehatan untuk pasien di rumah
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3. Persiapan pemulangan pasien
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