PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT 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 HEMODIALISA

Keluhan :

Data Objektif :

Cairan dialisat :

TMP :

Qd :

Qb :

Dosis Heparin :

Tanda vital:PENGKAJIAN POST HEMODIALISAKeadaan 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): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Denpasar, November 2013

Muhamad Royhan, S. Kep

NIM. 0723 11 1010 31EMBED Word.Picture.8

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