Format Askep Perioperatif-1.docx

PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN STASE KEPERAWATAN GADAR KRITIS TAHUN 2019

FORMAT ASKEP PERIOPERATIF I.

PENGKAJIAN IDENTITAS Nama (inisial)

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

No. RM

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

Usia

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

Jenis Kelamin

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

Alamat

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

Diagnosa medis

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

Tindakan operasi

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

A. PRE OPERASI 1) Persiapan operasi a.

Informed consent

: ada/ tidak

b.

Sedia darah

: ya/ tidak

Jenis darah

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

Jumlah

:...................................... cc

c.

Skeren

: ya/ tidak

d.

Baju operasi

: ya/ tidak

e.

Lokasi operasi

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

f.

Riwayat alergi/asma :......................................

g.

Saturasi O2 pre operasi

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

h.

Kesulitan bernafas

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

i.

Bleeding

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

j.

Persiapan operasi

: ( ) puasa

( ) cukur

( ) radiologi

( ) EKG

( ) USG

( ) lainnya :...........

2) Data DS

:

................................................................................................................................... ................................................................................................................................... ...................................................................................................................................

DO

: (Termasuk di dalamnya pemeriksaan TTV, pemeriksaan penunjang)

................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... Kesadaran :................................................................................................................. TD

:.......................mmHg

RR

:.......................x/m

HR

:......................x/m

Pemeriksaan penunjang : ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ................................................................................................................................... ...................................................................................................................................

B. INTRA OPERASI DS

:

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... DO

:

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Antibiotik profilaksis :....................................................................................................

Jenis anastesi

:

.......................................................................................................................................... .......................................................................................................................................... Efek anastesi

: ( sekresi lendir meningkat, reflek batuk)

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Kelengkapan Tim Operasi

: ( ) Operator ( ) asisten

( ) scrabners

( ) sirkulerners Tanda atau lokasi tindakan operasi : .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Sianosis

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

Suara nafas ngorok

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

Posisi saat pembedahan

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

Suhu tubuh pasien

:...............oC

Keadaan luka sayat operasi (lebar luka..................cm) lama pembedahan

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

Perdarahan

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

Urine

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

Terpasang alat infasif

: NGT/ IV line/ chateter urin

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Amati perubahan TTV setiap 15 menit sekali .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... ..........................................................................................................................................

C. POST OPERASI DS

:

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... DO

:

.......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Monitor TTV (TD, RR, HR, suhu) dan kesadaran tiap 15 menit : .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... Saturasi oksigen post operasi :........................... Penggunaan oksigen

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

Monitor tetesan infus

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

Posisi pasien

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

Spesimen (ada/ tidak)

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

Skore

: ( ) Steward score ( ) Bromage score

( ) Aldrete score

ANALISA DATA NO.

DATA

PROBLEM

ETIOLOGI

NO.

DATA

PROBLEM

ETIOLOGI

PRIORITAS MASALAH KEPERAWATAN : ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................

RENCANA ASUHAN KEPERAWATAN Diagnosa Keperawatan : ................................................................................................................................................................................... .......................................................................................................................................................................................................................... TUJUAN DAN KRITERIA HASIL

INTERVENSI

RASIONAL

IMPLEMENTASI DAN EVALUASI DIAGNOSA KEPERAWATAN

JAM

IMPLEMENTASI

PARAF

EVALUASI