Professional Documents
Culture Documents
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Riwayat Kesehatan
Keluhan Utama
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Riwayat Penyakit Sekarang
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Riwayat Kesehatan Dahulu
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Riwayat Kesehatan Keluarga
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Genogram :
Riwayat Sosiokultural
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3.
a.
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b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
4.
Pola Nutrisi-Metabolik
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Pola Eleminasi
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Pola Aktivitas dan Latihan
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Pola koqnitif dan Persepsi
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Pola Persepsi-Konsep diri
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Pola Tidur dan Istirahat
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Pola Peran-Hubungan
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Pola Seksual-Reproduksi
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Pola Toleransi Stress-Koping
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Pola Nilai-Kepercayaan
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PEMERIKSAAN FISIK
a.
b.
c.
d.
e.
f.
g.
h.
i.
Keadaan Umum
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Tanda Vital
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Kepala
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Mata
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Hidung
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Telinga
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Mulut
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Leher
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Dada dan Punggung
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j.
Abdomen
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k.
Ekstremitas
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l.
Genetalia
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m.
Anus
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5.
6.
B.
ANALISA DATA
Data
Etiologi
Masalah
Kolaboratif /
Keperawatan
C.
TANGGAL, JAM
LENYAP / TERATASI
PERENCANAAN
D. NO.
DIAGNOSA
NTASI
TUJUAN
INTERVENSI
RASIONAL
I
M
P
L
E
M
E
Hari/ Tgl/Jam
E.
No
No Dx
Tindakan Keperawatan
Evaluasi
Ttd
EVALUASI
Hari/Tgl
No Dx
Evaluasi
TTd
b.
:
:
:
Identitas Klien
Nama
:
Jenis Kelamin
:
Umur
:
Status
:
Agama
:
Tanggal masuk
Tanggal pengkajian
:
Riwayat Kesehatan
Dx Medis
:
Rencana Operasi
Proses Keperawatan
1. Pre Operasi (Ruang Persiapan Operasi)
- Data Fokus
- Evaluasi
- Intervensi/Implementasi
- Evaluasi
- Intervensi/Implementasi
Evaluasi
:
:
:
:
:
I.
Latar Belakang
II.
III.
IV.
Metode
V.
Media
VI.
Rencana Pembelajaran
No
Kegiatan Penyuluhan
1
Pembukaan
2
Pelaksanaan
3
Penutup
VII.
Materi
VIII.
Evaluasi
IX.
Daftar Pustaka
Waktu
Kegiatan audiens
Nama
Umur
Jenis kelamin
Ruang
:
:
:
:
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No RM
Tgl MRS
Dx Medis
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: ............................................
: ............................................
Kondisi klien :
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Alasan masuk RS :
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Data fokus :
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Diagnosa keperawatan (masalah)
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Tujuan khusus : tujuan yang akan dicapai, kriteria hasil
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Tindakan keperawatan : tindakan apa yang akan dilakukan, SOP tindakan tersebut
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ORIENTASI
o Salam terapeutik : ...................................................................................................................
o Evaluasi/validasi : ...................................................................................................................
o Kontrak
Topik
: .................................................................................................................................
Waktu : .................................................................................................................................
Tempat : .................................................................................................................................
KERJA
(Langkah-langkah tindakan keperawatan) : komunikasi saat melakukan tindakan
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TERMINASI
o Evaluasi respon klien terhadap tindakan keperawatan
o Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah
dilakukan
Keterangan: Format panduan ini dapat dimodifikasi disesuaikan dengan kebutuhan dan sumber yang
ada.
NAMA MAHASISWA
NIM
TANGGAL PRAKTIK
:
:
:
A. IDENTITAS KLIEN
Nama
:
Umur
:
Jenis Kelamin
:
Alamat
:
No. RM
:
Dx. Medis
:
B. PENGKAJIAN
Data Fokus
:
................................................................................................................................................................
................................................................................................................................................................
C. RENCANA
No. Dx. Keperawatan/
Masalah Kolaborasi
Tujuan
Implementasi
Evaluasi
NAMA MAHASISWA
NIM
TANGGAL PRAKTIK
:
:
:
A. IDENTITAS KLIEN
Nama
Umur
Jenis Kelamin
Alamat
Penanggung Jawab Biaya
Tanggal HD
No. RM
Dx. Medis
:
:
:
:
:
:
:
:
B. PENGKAJIAN
1.
Pre HD (meliputi: KU, BB, TTV, Pemeriksaan Fisik, Status cairan dan
elektrolit, Keluhan, dll.)
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2.
a.
b.
-
Data Hemodialisi:
Tanggal mulai HD
: ........................................................................................
Tipe dan lokasi akses vaskuler : ........................................................................................
Frekuensi HD/minggu
: ........................................................................................
Lama HD setiap sesi
: ........................................................................................
Jenis cairan dialisat
: ........................................................................................
Dosis dan metode heparinisasi : ........................................................................................
Rata-rata Blood Flow Rate (QB)
: ........................................................................................
Berat badan kering
: ........................................................................................
E. EVALUASI
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