Pot Pormat.docx

Asuhan Keperawatan Post Operatif Pada Tn.I Di Ruang Teratai Merah Bawah RSUD R. Syamsudin, SH Pada Tanggal 02 Oktober 2018

A. PENGKAJIAN 1. Exception Summary Data ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Penampilan Umum ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3. Pengkajian Terfocus a. Kesadaran

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

b. TTV

: TD

:

Nadi :

Suhu : RR

:

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

4. Pemeriksaan Penunjang 1) Terapi Obat Tanggal: Nama Obat

Rute

Dosis

Waktu Pemberian

2) Pemeriksaan Laboratorium Tanggal: Jenis

Hasil

Nilai Normal

Interpretasi

3) Ronstgen/USG/EKG ................................................................................................................................ ................................................................................................................................ ................................................................................................................................

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: .............................. No

Perencanaan

Diagnosa Keperawatan

Tujuan

Intervensi

Rasional

D. IMPLEMENTASI Tanggal No

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

Evaluasi Sumatif Shiff

Shift Kerja : Pagi/Siang/Malam Action

Respon

Tanggal: No

Shift Kerja: Pagi/Siang/Malam Data

Evaluasi Sumatif Shiff

Action

Respon

Shift

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

Tanggal

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

Evaluasi Sumatif Shiff

Action

Respon

Shift

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

Tanggal

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

Evaluasi Sumatif Shiff E. EVALUASI

Action

Respon

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