Asuhan_keperawatan_perioperatif.doc

ASUHAN KEPERAWATAN PERIOPERATIF PENGKAJIAN Hari/Tanggal

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Ruang / Jam

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Nama Mahasiswa

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NIM

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A. Identitas Pasien Nama

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Umur

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No. RM

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Jenis kelamin

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Alamat

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Pekerjaan

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Diagnosa Medis

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Tanggal masuk

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B. Penanggung Jawab Nama

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Umur

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Alamat

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Hubungan dg klien

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PRE OPERATIF A. DATA PASIEN Keadaan Umum ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... Keluhan Klien ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... Tanda-tanda Vital : TD :................................................................. Nadi :................................................................. RR :................................................................. Suhu :................................................................. Kesadaran:................................................................ Berat Badan :........................................................(Kg) Pemeriksaan Fisik (IPPA & Data Fokus) .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... ....................................................................................................

.................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... A. Pemeriksaan Fisik (Data Fokus) .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... A. Pemerikasaan Penunjang Labratorium dan Radiologi ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... B. Therapy ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... C. Persiapan Operasi Cairan parenteral: ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... Baju operasi : ............................................................................................................................... ............................................................................................................................... Inform consent:

............................................................................................................................... ............................................................................................................................... Kebersihan Colon / Blader: ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... D. ANALISA DATA (Pre Operatif) Data Fokus

Etiologi

Masalah

E. Diagnosa Keperawatan 1. ............................................................................................................ ............................ 2. ............................................................................................................ ..............................

F. NO

INTERVENSI KEPERAWATAN

Diagnosa

Tujuan dan Kriteria

Keperawatan

Hasil

Intervensi

Implementasi

Evaluasi

INTRA OPERASI A. Persiapan pasien di meja operasi 1. Jenis Anestesi ................................................................................................................................. ................................................................................................................................. ................................................................................................................................. 2. Tanda-tanda Vital : TD :................................................................. Nadi :................................................................. RR :................................................................. Suhu :................................................................. Kesadaran.................................................................: 3. Set Alat Operasi .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... 4. Laporan Jalannya Operasi (Gambaran saat mulai operasiproses-selesei) .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... ....................................................................................................

.................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... B. ANALISA DATA (Intra Operatif) Data Fokus

C. Diagnosa Keperawatan

Etiologi

Masalah

1. ............................................................................................................ ............................ 2. ............................................................................................................ ............................ 3. ............................................................................................................ ...........................

D. INTERVENSI KEPERAWATAN NO

Diagnosa

Tujuan dan Kriteria

Keperawatan

Hasil

Intervensi

Implementasi

Evaluasi

POST OPERASI B. Keadaan Umum ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... ............................................................................................................................... C. Tanda-tanda Vital : TD :................................................................. Nadi :................................................................. RR :................................................................. Suhu :................................................................. Kesadaran:................................................................ D. Pemeriksaan Fisik (Data Fokus) .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... E. ANALISA DATA (Intra Operatif) Data Fokus

Etiologi

Masalah

F.

Diagnosa Keperawatan 1. ............................................................................................................ .............................. 2. ............................................................................................................ .............................. 3. ............................................................................................................ ..............................

G. INTERVENSI KEPERAWATAN NO

Diagnosa

Tujuan dan Kriteria

Keperawatan

Hasil

Intervensi

Implementasi

Evaluasi