FORMAT LAPORAN ASUHAN KEPERAWATAN

DI UNIT HEMODIALISA

Nama mahasiswa :
Tanggal Praktek :
Nama Pasien :
Umur / Jenis kelamin :
Hemodialisa Ke :
Pengkajian Keperawatan :

A. IDENTITAS PASIEN
1. Nama (Inisial) :
2. Usia / tanggal lahir :
3. Jenis kelamin :
4. Alamat :
5. Suku / bangsa :
6. Status pernikahan :
7. Agama / keyakinan :
8. Pekerjaan / sumber penghasilan :
9. Diagnosa medic :
10. No. RM :
11. Tanggal masuk :
B. IDENTITAS PENANGGUNG JAWAB
1. Nama :
2. Usia :
3. Jenis kelamin :
4. Pekerjaan / sumber penghasilan :
5. Hubungan dengan pasien :
C. KELUHAN UTAMA
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D. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Sekarang
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2. Riwayat Kesehatan Lalu
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3. Riwayat Kesehatan Keluarga
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E. POLA KEBUTUHAN DASAR
1. Pola Persepsi Dan Pemeliharaan Kesehatan
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2. Pola Eliminasi
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3. Pola Aktifitas Dan Latihan
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4. Pola Istirahat Dan Tidur
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5. Pola Nutrisi-Metabolik
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6. Pola Kognitif-Perseptual Sensori
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7. Pola Persepsi Diri Dan Konsep Diri
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8. Pola Mekanisme Koping
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9. Pola Seksual-Reproduksi
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10. Pola Peran-Berhubungan Dengan Orang Lain
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11. Pola Nilai Dan Kepercayaan
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F. PEMERIKSAAN FISIK
1. Kepala
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2. Neuro
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3. Mata
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4. Hidung
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5. Mulut
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6. Leher
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 7. Dada
Jantung
Inspeksi:..........................................................................................................................
Palpasi :...........................................................................................................................
Perkusi :..........................................................................................................................
Auskultasi :.....................................................................................................................
Paru-paru
Inspeksi :.........................................................................................................................
Palpasi :...........................................................................................................................
Perkusi :..........................................................................................................................
Auskultasi :.....................................................................................................................
8. Abdomen
Inspeksi :.........................................................................................................................
Auskultasi :.....................................................................................................................
Palpasi :...........................................................................................................................
Perkusi :..........................................................................................................................
9. Ekstremitas Atas dan Bawah
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10. Integument
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G. Pre HD
1. KU :
2. Kesadaran :
3. BB Pre HD :
4. BB Post HD yang lalu:
5. Penambahan BB :
6. Jenis dialyzer :
7. Asetat :
8. Bicarbonat :
9. Heparinisasi :
10. TTV
TD :
HR :
RR :
S :
11. ANALISA DATA
Tgl/jam Data Fokus Etiologi Problem TTD

12. DIAGNOSE KEPERAWATAN

13. INTERVENSI
Tgl/jam D Tujuan dan Kriteria Intervensi TTD
X Hasil
14. IMPELEMNTASI
Tgl/jam DX Implementasi Respon TTD
15. EVALUASI

Tgl/jam DX Evaluasi TTD

H. Selama Pelaksanaan HD
MONITOR
No Imp Jam QB VP TMP Temp Tensi Nadi RR Skala Ket Nama
DX (ml/mnt) (mm/hg) Nyeri Perawat
I. Post HD
1. ANALISA DATA
Tgl/jam Data Fokus Etiologi Problem TTD

2. DIAGNOSE KEPERAWATAN

3. INTERVENSI
Tgl/jam D Tujuan dan Kriteria Intervensi TTD
X Hasil
4. IMPELEMNTASI
Tgl/jam DX Implementasi Respon TTD
5. EVALUASI
a. Implementasi Diagnosa

Tgl/jam DX Evaluasi TTD

b. Komplikasi Intra HD dan Post HD:

c. BB Post HD :
d. Cairan Masuk
1) Premming :
2) Wash Out :
3) Transfusi :
4) Minum :
Jumlah :
e. Cairan Keluar
1) Urine :
2) Muntah :
3) Perdarahan :
Jumlah :