No RM :

ASUHAN KEPERAWATAN PASIEN

CONTINUOUS AMBULATORY PERITONEAL Nama :
Jl. Pasteur No 38 Bandung DIALISIS (CAPD)
Telp (022) 2034953-55 INSTALASI HEMODIALISA Tgl Lahir :
(L/P*)
Halaman 1 dari 2

Tanggal : - - Jam : ………………WIB

Asal Pasien :  Rawat Jalan  Rawat Inap  Unit Gawat Darurat
Penanggung :  BPJS PBI  BPJS Non PBI  Lain-lain……………………
Diagnosa medis : …………………….……………………………………………..……………….
I. DIAGNOSA MEDIS :
A. KELUHAN UTAMA / ALASAN MASUK RUMAH SAKIT
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B. PEMERIKSAAN FISIK
1. Keadaan umum :  Baik  Sedang  Buruk
2. Tingkat Kesadaran:  Compos mentis  Apatis  Delirium  Somnolen  Sopor  Koma
3. Tanda Vital : Tekanan darah…........mmHg Nadi……….kali/menit
Respirasi………….kali/menit Suhu……….0C
4. Berat badan : …………. Kg Tinggi badan : ………… cm
5. Exit site : …………………….
6. Skala nyeri :…………..
Tidak Nyeri 0
Ringan 1–3
Sedang 4–6
Berat 7 – 10
Akut Kronik

7. Resiko jatuh : score……………

Kesimpulan :  0-24 (risiko rendah)  >24 - 45 (risiko sedang)  >45 (risiko tinggi)

C. PEMERIKSAAN PENUNJANG
1. LABORATORIUM
1. Jumlah Sel ………….. 2. Ureum ………….. 3. Natrium ………….. 4. Fe Serum …………..
5. Hitung Jenis ………….. 6. Kreatinin ………….. 7. Kalsium ………….. 8. TIBC …………..
9. Hemoglobin ………….. 10. Kalium ………….. 11. Gu ………….. 12. Sat. Transfer …………..
la darah
13. Protein Total ………….. 14. Albumin ………….. 15. Lain-lain …………..
2. PEMERIKSAAN DIAGNOSTIK
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II. PERESEPAN CAPD

1. Jenis cairan dianeal :  1,5%  2,5%
 4,25%  Extraneal/Icodextrin  Nutrineal
2. Frekuensi pertukaran cairan :  3 kali/hari  4 kali/hari  ……. kali/hari
3. Pergantian cairan :
Volume masuk : ………….. cc Waktu : …………… menit
Volume keluar : …………… cc Waktu : …………... menit
Balance : …………… cc
4. Warna cairan : ………………………………………..

III. DIAGNOSA KEPERAWATAN

 1. Kelebihan volume cairan  2. Kekurangan volume cairan  3. Resiko infeksi

 4. Gangguan rasa nyaman: nyeri  5. Resiko ketidakseimbangan elektrolit  6. Resiko ketidakseimbangan cairan

 7. Gangguan pertukaran gas  8. Nausea  9. Intoleran aktivitas

 No RM :
ASUHAN KEPERAWATAN PASIEN
CONTINUOUS AMBULATORY PERITONEAL Nama :
Jl. Pasteur No 38 Bandung DIALISIS (CAPD)
Telp (022) 2034953-55 INSTALASI HEMODIALISA Tgl Lahir :
(L/P*)
Halaman 1 dari 2

 10. Kurang pengetahuan  11. Nurisi kurang dari kebutuhan 

*) Coret yang tidak perlu dan beri tanda √ pada  sesuai pilihan

IV.INTERVENSI KEPERAWATAN
Mandiri :
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Kolaborasi :
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V. TINDAKAN KEPERAWATAN
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VI.EVALUASI KEPERAWATAN
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VII. RENCANA KEPULANGAN PASIEN (DISCHARGE PLANNING) :

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 No RM :
ASUHAN KEPERAWATAN PASIEN
CONTINUOUS AMBULATORY PERITONEAL Nama :
Jl. Pasteur No 38 Bandung DIALISIS (CAPD)
Telp (022) 2034953-55 INSTALASI HEMODIALISA Tgl Lahir :
(L/P*)
Halaman 1 dari 2

Petugas,

(………………………………………………………)
Tanda Tangan dan Nama Jelas

*) Coret yang tidak perlu dan beri tanda √ pada  sesuai pilihan