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I. IDENTITAS PASIEN DAN PENANGGUNG JAWAB 1. IDENTITAS PASIEN Nama

:

Usia

:

Jenis kelamin

:

No. rekam medic : Diagnosa medis

:

Tanggal masuk RS : Tanggal Pengkajian: Alamat

:

2. IDENTITAS PENENGGUNG JAWAB Nama : Umur

:

Pendidikan

:

Pekerjaan

:

Alamat

:

Hub. Dg klien

:

II. PENGKAJIAN 1. KELUHAN UTAMA .................................................................................................................................... .................................................................................................................................... 2. RIWAYAT KESEHATAN a. Riwayat kesehatan sekarang ............................................................................................................................... ............................................................................................... ............................................................................................................................... .......................................................................................................... b. Riwayat kesehatan dahulu ............................................................................................................................... ............................................................................................................................... ..........................................................................................................................

c. Riwayat kesehatan keluarga ............................................................................................................................... ............................................................................................... ............................................................................................................................... ............................................................................................... d. Pola Aktifitas Sehari- hari No

Jenis Aktifitas

1

Nutrisi

2

Eliminasi

Di Rumah

Di RS

BAB

BAK

3

Istirahat /tidur

4

Ambulasi

5

Kebersihan diri

e. Pengkajian fisik  Sistem respirasi dan oksigenisasi ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................



f.

Sistem kardiovaskuler ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................  Sistem gastrointetinal ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................  Sistem neurologi ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................  Sistem skeletal ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................  Sistem urogenital ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................  Sistem integumen ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ Hasil pemeriksaan diagnostik

A. pre Operasi

Dignosa

:

Informed consent :

Persiapan kamar bedah 1. Alat operatif steril 2. Meja/tempat tidur operasi 3. Monitor 4. Standart infuse 5. Suction 2. Pelaksanaan pembedahan -

Operator

:

-

Asisten/Instrument :

-

Perawat onloop

:

-

Anastesi

:

-

Penata

-

Jenis anastesi

:

-

Obat anastesi

:

:

3. Persiapan instrument ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

............................................................................................................................................... ............................................................................................................................................... B. Intra Operatif

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

Pukul .............................................................................................................................................. ..............................................................................................................................................

C. Post Operatif .............................................................................................................................................. ..............................................................................................................................................

TTV: Tekanan darah

:

Suhu

:

Nadi

:

RR

:

SPO2 Do

: :

.............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. DS

:

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

Instruksi dokter bedah: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ..............................................................................................................................................

Instruksi dokter anastesi : .............................................................................................................................................. ..............................................................................................................................................

III.

Analisa data Data

Etiologi

Probblem

IV.RENCANA ASUHAN KEPERAWATAN No.

Diagnosa Keperawatan

Tujuan

Intervensi

Rasional

V. IMPLEMENTASI Hari tanggal

/ No. DP

Implementasi

Evaluasi

VI. EVALUASI nO

Hari/tanggal

Diagnosa Keperawatan

Evaluasi

LAPORAN KASUS ASUHAN KEPERAWATAN PASIEN ...............DENGAN GANGGUAN SISTEM .............................:......................................................... DI RUANG INSTALASI BEDAH SENTRAL RSUD KOTA BANDUNG

NAMA :................................ NPM :....................................

PROGRAM PROFESI NERS STASE KEPERAWATAN MEDICAL BEDAH SEKOLAH TINGGI ILMU KESEHATAN BHAKTI KENCANA BANDUNG 2018