PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN RESUME KASUS KELOLAAN HARIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :

IDENTITAS KLIENNama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal Pengkajian :Alamat : Sumber Informasi :Diagnosa Medis

:

PENGKAJIAN PRE HEMODIALISA

Keadaan umum:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Keluhan :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..………………………………………………………………………………………..……………………………………………………………………………………………………………………

BB :

Status cairan dan elektrolit :

Tanda vital:

PENGKAJIAN INTRA HEMODIALISAKeluhan :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Objektif :Cairan dialisat :

TMP :

Qd :

Qb :

Dosis Heparin :

Tanda vital:

PENGKAJIAN POST HEMODIALISA

Keadaan umum :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...Keluhan :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….......BB :

Status cairan dan elektrolit :

Tanda vital:

S (Subjektif): ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif):........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P(Perencanaan):........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

I (Implementasi):................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

E (Evaluasi)S(Subjektif): ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O(Objektif): ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………

A(Analisa): ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P(Perencanaan): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, September 2015