ASUHAN KEPERAWATAN
PERIOPERATIF
I.
PENGKAJIAN
A. PRE OPERASI/PRE MEDIKASI
1.
Serah terima pasien
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
2.
Identitas Pasien
Nama : ……………………………………..
Umur : ……………………………………..
Alamat : ……………………………………..
Diagnosa Medik :……………………………………...
Tindakan Op. : ……………………………………..
3.
Pemeriksaan Fisik/Psikologi
TTV : ………………………………………………………………………
Reaksi Fisik :………………………………………………………………………..
Reaksi
Psikologi :
……………………………………………………………………….
Persiapan Operasi :
Informed
Concent/Ijin Anestesi Puasa Cukur
Pemeksaan Penunjang: Lab Radiologi EKG
Pre medikasi
…………………………………………………………………………………………………………………………………………………………………………………………………………
B. INTRA OPERASI
1.
Kelengkapan Tim
Operasi
Bedah
:……………………………… Anestesi :………………………Jenis Anestesi……….
2.
Tanda daerah operasi: Lokasi…………………………………………………………….
3.
Kelengkapan Anestesi: IV Line:…………………………………………………………..
Obat-obatan: ……………………………………………………
4.
Riwayat asma/alergi:……………………………………………………………………….
5.
Posisi operasi:………………………………………………………………………………
6.
Rencana dilakukan tindakan:………………………………………………………………
7.
Observasi tindakan operasi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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8.
Observasi tindakan anestesi
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9.
Pemeriksaan kelengkapan
Kasa:………………………..jarum:……………………..Instrumen:…………………….
10. Pemeriksaan cairan/jaringan
tubuh: ada tidak ada
…………………………………………………………………………………………………………………………………………………………………………………………………………
C.
POST
OPERASI/PASCA ANESTESI
1. Air way
…………………………………………………………………………………………………………………………………………………………………………………………………………
2. Breathing
…………………………………………………………………………………………………………………………………………………………………………………………………………
3. Cirkulasi
…………………………………………………………………………………………………………………………………………………………………………………………………………
4. Observasi RR
Steward Scor Aldrete Scor Bromage Scor
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5.
Serah terima pasien
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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II.
ANALISA DATA
A. Pre Operasi
DATA
|
ETIOLOGI
|
MASALAH
|
B. Intra Operasi
DATA
|
ETIOLOGI
|
MASALAH
|
C. Post Operasi
DATA
|
ETIOLOGI
|
MASALAH
|
III.
INTERVENSI, IMPLEMENTASI
& EVALUASI ASUHAN KEPERAWATAN
A. PRE OPERASI
NO.
|
DIAGNOSA KEPERAWATAN
|
NOC
|
NIC
|
IMPLEMENTASI
|
EVALUASI
|
B. INTRA OPERASI
NO.
|
DIAGNOSA KEPERAWATAN
|
NOC
|
NIC
|
IMPLEMENTASI
|
EVALUASI
|
C. POST OPERASI
NO.
|
DIAGNOSA KEPERAWATAN
|
NOC
|
NIC
|
IMPLEMENTASI
|
EVALUASI
|
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