2. Askep Pre Operatif (kep. Dewasa) (1).docx

Asuhan Keperawatan Pre Operatiif Pada Tn.I dengan Gangren Digiti 5 Pedis Dextra Di Ruang Teratai Merah BAwah RSUD R. Syamsudin, SH Pada Tanggal 01 Oktober 2018

A. PENGKAJIAN 1. Deskripsi Pasien Nama

: .......................................................................................................

Umur

: .......................................................................................................

Jenis Kelamin

: .......................................................................................................

Alamat

: .......................................................................................................

No. CM

: .......................................................................................................

Tanggal Masuk : ....................................................................................................... Dx. Medis

: .......................................................................................................

2. Exception Summary Data ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3. Penampilan Umum ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................

...................................................................................................................................... 4. Pengkajian Terfocus a. Anamnesa 1) Keluhan Utama .......................................................................................................................... .......................................................................................................................... 2) Riwayat Kesehatan Sekarang .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 3) Riwayat Kesehatan Masalalu .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... b. Pemeriksaan Fisik 1) Kesadaran

: ................................................................................................

2) TTV

: TD

:

Nadi :

Suhu : RR

:

3) Head to Toe .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................

.......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... F. Data Penunjang 1) Terapi Obat Tanggal: Nama Obat

Rute

Dosis

Waktu Pemberian

Nilai Normal

Interpretasi

2) Pemeriksaan Laboratorium Tanggal: Jenis

Hasil

3) Ronstgen/USG/EKG .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... 5. Persiapan Pre Operatif Jenis Cukur Darah Puasa Gigi Palsu Lensa Kontak Cincin Surat Izin Tindakan Hasil Lab Rontgen Urin Kateter

Ya

Tidak

B. ANALISA DATA 1. Analisa Data No

Data

Etiologi

Masalah

2. Diagnosa Keperawatan ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................

C. NURSING CARE PLAN Rencana Asuhan Keperawatan ..... Di Ruang ........................................ Dibuat Tanggal .............................. Nama Perawat Primer: .............................. No

Perencanaan

Diagnosa Keperawatan

Tujuan

Intervensi

Rasional

D. IMPLEMENTASI Shift

: ....................................

Tanggal

:.................................... Data

Evaluasi Sumatif Shiff

Action

Respon

Shift

: ....................................

Tanggal

:.................................... Data

Evaluasi Sumatif Shiff

Action

Respon

Shift

: ....................................

Tanggal

:.................................... Data

Evaluasi Sumatif Shiff

Action

Respon

E. EVALUASI ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................