3. Askep Intra Operatif (kep.docx
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Asuhan Keperawatan Intra Operatiif Pada ..... Di Kamar Operasi No ........................................ RSUD R. Syamsudin, SH Tanggal ........................................
A. PENGKAJIAN KEPERAWATAN Hari .......... Tanggal .................... Jam Mulai .......... 1. Penampilan Umum ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Keluhan Utama ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3. Pemeriksaan Fisik a. Tanda Vital ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ b. Fokus ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................
c. Alat Invasif yang Terpasang ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 4. Ceklis dan Validasi a. Biografi Nama
: ..........................................................................................................
Umur
: ..........................................................................................................
Alamat
: ..........................................................................................................
No. CM
: ..........................................................................................................
b. Lokasi Pembedahan ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ d. 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 Data (Suby dan Oby)
Rumusan Masalah / Problem dan Penyebab / Etiologi Pre Op
Intra Op
Post Op
C. PERENCANAAN Nomor Diagnosa Perawatan
Hasil yang Diharapkan (Harus SMART)
Rencana Intervensi Pre Op
Intra Op
Post Op
D. IMPLEMENTASI Shift
: ....................................
Tanggal
: .................................... Data
Evaluasi Sumatif Shiff
Action
Respon
E. LEMBAR OBSERVASI Waktu
Tekanan Darah
Nadi
Respirasi
Suhu
SP02
Intake/Output Rom/Aktifitas
Integumen
Keterangan
F. DATA PENUNJANG 1. Laboratorium Tanggal
Jenis Pemeriksaan
Hasil
Nilai Normal
Keterangan
2. Terapi Obat Tanggal
Nama Obat
Rute
Dosis
Waktu Pemberian
A. PENGKAJIAN KEPERAWATAN Hari .......... Tanggal .................... Jam Mulai .......... 1. Penampilan Umum ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Keluhan Utama ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3. Pemeriksaan Fisik a. Tanda Vital ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ b. Fokus ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................
c. Alat Invasif yang Terpasang ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ 4. Ceklis dan Validasi a. Biografi Nama
: ..........................................................................................................
Umur
: ..........................................................................................................
Alamat
: ..........................................................................................................
No. CM
: ..........................................................................................................
b. Lokasi Pembedahan ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ d. 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 Data (Suby dan Oby)
Rumusan Masalah / Problem dan Penyebab / Etiologi Pre Op
Intra Op
Post Op
C. PERENCANAAN Nomor Diagnosa Perawatan
Hasil yang Diharapkan (Harus SMART)
Rencana Intervensi Pre Op
Intra Op
Post Op
D. IMPLEMENTASI Shift
: ....................................
Tanggal
: .................................... Data
Evaluasi Sumatif Shiff
Action
Respon
E. LEMBAR OBSERVASI Waktu
Tekanan Darah
Nadi
Respirasi
Suhu
SP02
Intake/Output Rom/Aktifitas
Integumen
Keterangan
F. DATA PENUNJANG 1. Laboratorium Tanggal
Jenis Pemeriksaan
Hasil
Nilai Normal
Keterangan
2. Terapi Obat Tanggal
Nama Obat
Rute
Dosis
Waktu Pemberian
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