Resume Hemodialisa
Resume Hemodialisa
1. Biodata pasien:
Nama :.....................................................................................................................
Umur :......................................................................................................................
No RM :......................................................................................................................
Alamat :......................................................................................................................
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2. Diagnosa medis : ...................................................................................................................
3. Tgl & jam
pengkajian :...........................................................................................................
4. Data focus :
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5. KU pasien :......................................................................................................................
6. TTV :
TD : , Suhu: Nadi : RR :
7. BB sekarang : kg
8. BB yang lalu : kg
9. BB kering : kg
10. Hasil pemeriksaan laboratorium :
a. HB :
b. Ureum :
c. Creatinine :
d. HbSag :
e. HCV :
f. HIV :
g. Kalium :
h. SGOT :
i. SGPT :
j. Hasil pemeriksaan lain :
11. Masalah keperawatan :
a. …………………………………………………………..
b. …………………………………………………………..
c. …………………………………………………………..
12. Tindakan keperawatan :
a. ……………………………………………………………
b. ……………………………………………………………
c. ……………………………………………………………
d. ……………………………………………………………
e. ……………………………………………………………
13. Evaluasi :
a. ……………………………………………………………
b. ……………………………………………………………
c. ……………………………………………………………
2. DATA FOKUS
a. Data Subyektif :
b. Data Obyektif :
c. Kesadaran : GCS :
d. Vital Sign :TD: Nadi: Suhu: RR:
3. MASALAH KEPERAWATAN :
a. ................................................................................................................................................
b. ................................................................................................................................................
b. Pengobatan selama HD
1) Transfusi darah : goldar :
2) Eritropoetin : Hemapo/ Recormon / Epprex :2000 iu /3000 iu / 5000 iu
3) Obat yang diberikan : dosis :
4) Pengawasan cairan selama HD
a) Volume Priming : cc
b) Cairan masuk : cc
c) Sisa Priming : cc
d) Cairan Drip : cc
e) Darah : cc
f) Wash out : cc
Jumlah : cc
c. 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 :
EVALUASI
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n. TINDAKAN KEPERAWATAN
1) ................................................................................................................................................
2) ................................................................................................................................................
3) ................................................................................................................................................
4) ................................................................................................................................................
5) ................................................................................................................................................
o. Planing :
1) HD selanjutnya tgl :
2) Lama HD : jam
p. EVALUASI
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