Format Laporan Stase Kmb
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Laporan Resume :AsuhanKeperawatan Unit Hemodialisa STASE KMB
ASUHAN KEPERAWATAN PADA KLIEN _____DENGAN _____________________DI RUANG______________
RUMAH SAKIT __________________
Tgl. Masuk : …………………..Jam : …………………..No. RM : …………………..Tgl. Pengakjian :…………………..
IDENTITAS PASIENPASIEN PENANGGUNG JAWAB PASIENNamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _______________________ _______________________ _______________________
NamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _____________________________________________________________________
RIWAYAT KESEHATAN
ANAMNESA DAN KELUHAN UTAMA
RIWAYAT PENYAKIT DAHULUPenyakitdahulu :____________________________________________________________________Perlukaan :____________________________________________________________________Di rawat di RS :____________________________________________________________________Alergiobat/makanan : _______________________________________________________________Obat-obatan yang telahdikonsumsi :_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RIWAYAT KELUARGAHipertensi Penyakitpembuluhdarah Diabetes Militus PenyakitDarah Lain-lain ___________________________________________________________________________________
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______________________________________________________________________________________________________________________________________________________________________
PEMERIKSAAN FISIK
FokusSistemPerkemihan (Ginjal) :BB :__________TB:__________TD:_________
a. Frekwensi BAK :___________x/hari (sebelum sakit)b. Pola BAK : spontan kateter: jenis_________, sejak_____ urostomy nefrostomy c. Output urine : ___________ cc/ harid. Keluhan dalam BAK:
a) Dysuria: Ya Tidak, b) Inkontinnensia: Ya Tidak, c) Urgensi: Ya Tidak, d) Frekwensi: Ya Tidak, e) Hesistensi: Ya Tidak, f) Nokturia : Ya Tidak, g)
e. Pemeriksaan fisikperkemihana) Abdomen :
(1) Distensi : Ya Tidak(2) Perusi redup : Ya, area_________ Tidak(3) Teraba massa : Ya, area_________ Tidak(4) Nyeri tekan CVA : Ya Tidak(5) Nyeri ketuk : Ya Tidak
b) Ginjal kanandankiri(1) Massa: Ya,ginjalkanan/ kiri, ukuran____, mobilitas_____ Tidak(2) Nyeri tekan : Ya, ginjalkanan/ kiri Tidak
c) Vesika urinaria: Penuh Kosong Nyeri tekan
d) Cairan, sirkulasi, elektrolit dan asam basaa. Pengkajianperilaku
1) Intake cairan : oral , _____cc/24 jam IV, _____cc/24 jam2) Balance cairan : Intake :______________________________=______
Output:_______________________________=______Balance:_______
3) Turgor : normal jelek. Mukosa: kering lembab4) Akral : hangat/ dingin, CRT____detik5) TD_____mmHg, nadi___x/menit, reguler/tidak, kuat/ dangkal, RR___x/menit,
Suhutubuh____JVP ___________ mmHg.6) Terapidialisis : ya, jenis______tidak; BB pre dialisis :_____BB post
dialisis____IDWG____kg (____%)7) Edema ekstrimitas : ya , area________________ tidak8) Perdarahan : ya , area_______jumlah______ tidak9) Pemeriksaanlaboratorium: Ht…………Hb………natrium………
kalium……….clorida…………AGD:…………………………………………ureum…………kreatinin……….Albumin………CCCT……….Lain-lain………………………………………………………………
Pemeriksaan Fisik Penunjang Pada Sistem Lain
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DiagnosaKeperawatan :1.2.Intervensi:NOC :
NIC :
ImplementasiWaktu (jam) :
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EvaluasiWaktu (jam) :
Perawat : TandaTangan :
Resume :AsuhanKeperawatan Unit Hemodialisa
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Laporan Resume Asuhan Keperawatan Ruang Perawatan /Bangsal Medikal Bedah
ASUHAN KEPERAWATAN PADA KLIEN _____DENGAN _____________________DI RUANG______________
RUMAH SAKIT __________________
Tgl. Masuk : …………………..Jam : …………………..No. RM : …………………..Tgl. Pengakjian :…………………..
IDENTITAS PASIENPASIEN PENANGGUNG JAWAB PASIENNamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _______________________ _______________________ _______________________
NamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _____________________________________________________________________
RIWAYAT KESEHATAN
ANAMNESA DAN KELUHAN UTAMA
RIWAYAT PENYAKIT DAHULUPenyakitdahulu :____________________________________________________________________Perlukaan :____________________________________________________________________Di rawat di RS :____________________________________________________________________Alergiobat/makanan : _______________________________________________________________Obat-obatan yang telah dikonsumsi :_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RIWAYAT KELUARGAHipertensi Penyakitpembuluhdarah Diabetes Militus PenyakitDarah Lain-lain __________________________________________________________________________________
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PEMERIKSAAN FISIK FOKUS (SISTEM TERKAIT)
PEMERIKSAAN FISIK SISTEM TAMBAHAN/LAIN
DiagnosaKeperawatan :1.2.Intervensi:Tujuan keperawatan NOC :
NIC :
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ImplementasiWaktu :
Evaluasi
Waktu :
Perawat : TandaTangan :
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FORMAT LAPORAN ASKEP STASE KMB
ASUHAN KEPERAWATAN PADA KLIEN _____DENGAN _____________________DI RUANG______________
RUMAH SAKIT __________________
Tgl. Masuk : …………………..Jam : …………………..No. RM : …………………..Tgl. Pengakjian :…………………..
IDENTITAS PASIENPASIEN PENANGGUNG JAWAB PASIENNamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _______________________ _______________________ _______________________
NamaUmurAgamaPendidikanPerkerjaanStatus PernikahanAlamat
:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________:_______________________ _____________________________________________________________________
RIWAYAT KESEHATAN
KELUHAN UTAMA
RIWAYAT PENYAKIT SEKARANG
Waktuterjadinyasakit :__________________________________________________________________________________Proses terjadinyasakit:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Upaya yang telahdilakukan:_____________________________________________________________________________________________________________________________________________________________________Hasilpemeriksaansementara/sekarang:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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RIWAYAT PENYAKIT DAHULUPenyakitdahulu :____________________________________________________________________Perlukaan :____________________________________________________________________Di rawat di RS :____________________________________________________________________Alergiobat/makanan: _______________________________________________________________Obat-obatan yang telah dikonsumsi :_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RIWAYAT KELUARGAHipertensi Penyakitpembuluhdarah Diabetes Militus PenyakitDarah Lain-lain _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
GENOGRAM
POLA FUNGSI KESEHATAN
POLA MANAJEMEN KESEHATAN – PERSEPSI KESEHATANTingkat pengetahuankesehatan/penyakit:______________________________________________________________________________________________________________________________________________________________________Perilakuuntukmengatasimasalahkesehatan :______________________________________________________________________________________________________________________________________________________________________Faktor-Faktorresikosehubungandengankesehatan :___________________________________________________________________________________
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___________________________________________________________________________________POLA AKTIVITAS DAN LATIHANSebelumSakitAktivitas 0 1 2 3 4 Kemampuanperawatandiri :
Skor :0 : mandiri1 : dibantusebagian2 : perlubantuan orang lain3 : bantuan orang lain danalat4 : tergantung/tidakmampu
MandiBerpakaianEliminasiMobilisasi T. tidurBerpindahAmbulasi
SelamaSakitAktivitas 0 1 2 3 4 Kemampuanperawatandiri :
Skor :0 : mandiri1 : dibantusebagian2 : perlubantuan orang lain3 : bantuan orang lain danalat4 : tergantung/tidakmampu
MandiBerpakaianEliminasiMobilisasi T. tidurBerpindahAmbulasiNaiktangga
POLA ISTIRAHAT TIDURSebelumSakit SelamaSakit
POLA NUTRISI METABOLIK
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POLA ELIMINASISebelumSakit SelamaSakit
POLA KOGNITIF PERSEPTUAL
POLA KONSEP DIRI
GambaranDiri :
IdentitasDiri :
PeranDiri :
Ideal Diri :
HargaDiri :
POLA TOLERANSI STRES-KOPING
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POLA REPRODUKIF – SEKSUALITAS
POLA HUBUNGAN PERAN
POLA NILAI DAN KEYAKINANSebelumSakit SelamaSakit
PEMERIKSAAN FISIK
PENAMPAKAN UMUMKeadaan umum
KesadaranGCSTD : Suhu: RR : Nadi :
Beratbadan TinggiBadan
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SkalaNyeriHEAD TO TOE
KEPALA DAN LEHERRambut :
Mata :
Telinga :
Hidung :
Mulut :
Gigi :
Leher :
DADAInspeksi:
Palpasi:
Perkusi :
Auskultasi :
JANTUNGInspeksi :
Palpasi :
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Perkusi :
Auskultasi :
ABDOMENInspeksi :
Auskultasi :
Perkusi :
Palpasi :
INGUINAL & GENETALIAInspeksi :
Palpasi :
EKSTRIMITASInspeksi : Kekuatanotot
Palpasi :
________________________, _____ ___________________2011
DikajiOleh
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(_____________________________________)
PEMERIKSAAN PENUNJANG
WaktuJenis Pemeriksaan Hasil Pemeriksaan Nilai Rujukan
Tgl dan Jam
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TERAPI OBAT
WaktuJenisObat Dosis
Tgldan Jam
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ANALISA DATA
WAKTUSYMTOM/SIGNS ETIOLOGI PROBLEM
TGL/JAM
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DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH
1. _____________________________________________________________________________
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2. _____________________________________________________________________________3. _____________________________________________________________________________4. _____________________________________________________________________________5. _____________________________________________________________________________
waktu No.dx
Tujuankeperawatan (noc)
RencanaTindakan (nic) TtdHr/tgl jam
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waktu No.dx
Tujuankeperawatan (noc)
RencanaTindakan (nic) TtdHr/tgl jam
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Catatan Perkembangan
Diagnose Keperawatan :Hari/tanggal :Shift :
Jam IMPLEMENTASI Evaluasi Ttd
Ds :
Do:
A :
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P:
Catatan Perkembangan
Diagnose Keperawatan :Hari/tanggal :Shift :
Jam IMPLEMENTASI Evaluasi Ttd
Ds :
Do:
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A :
P: