FORMAT PENGKAJIAN KEPERAWATAN

RESUME KEPERAWATAN MEDIKAL BEDAH

PRODI DIII KEPERAWATAN UNIVERSITAS BONDOWOSO
Nama Mahasiswa
NIM
Tempat Pengkajian
Tanggal

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IDENTITAS KLIEN
Nama
:
Umur
:
Jenis Kelamin :
Agama
:
Pendidikan
:
Alamat
:
Diagnosa
:
Medis

No. RM
Pekerjaan
Status Perkawinan
Tanggal MRS
Tanggal Pengkajian
Sumber Informasi

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PROSES KEPERAWATAN
PRE HEMODIALISA
1) Data Fokus
Data Subjektif:
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Data Objektif:
BB Pre HD
Tanda vital:

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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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INTRA HEMODIALISA
1) Data Fokus
Data Subjektif:
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Data Objektif:
Cairan dialisat :
TMP :
Qd :
Qb :
Dosis Heparin :
Tanda vital:

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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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POST HEMODIALISA
1) Data Fokus
Data Subjektif:
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......................................................................................................................................
......................................................................................................................................
Data Objektif:
BB Post HD
Tanda vital:

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2) Diagnosa Keperawatan
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3) Intervensi Keperawatan
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4) Implementasi Keperawatan
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5) Evaluasi Keperawatan (SOAP)
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