SEKOLAH TINGGI ILMU KESEHATAN

HUTAMA ABDI HUSADA

Ijin Pendirian Mendiknas RI Nomor : 113/D/O/2009

Jl. Dr. Wahidin Sudiro Husodo Telp./Fax: 0355-322738

Tulungagung 66224
Alamat E-mail : akperta@gmail.com

FORMAT PENGKAJIAN
DI KAMAR OPERASI
NO. MR :

Diagnosa medis : .............. Dikirim tanggal : ...........

Tanggal pengkajian : ..... Dikirim ruangan : ...........
Jam : .... Jenis Operasi :

PRE OPERASI

A. IDENTITAS KLIEN
Nama : ...
Umur :
Jenis kelamin :
Suku / bangsa :
Agama :
Pendidikan : .
Pekerjaan : .
Alamat : ..
Biaya oleh : BPJS / Sendiri / Lain-lain ...................

B. RIWAYAT KEPERAWATAN (NURSING HISTORY)

Keluhan Utama :
1. Di rumah:
...............................................................................................................................
.......................................................................................
2. Saat pengkajian:
.................................................................................................................................................
.................................................................................................................................................
.
3. Riwayat Penyakit (PORST):
Di rumah:
...............................................................................................................................
.......................................................................................
Saat pengkajian:
.................................................................................................................................................
...............................................................................................................................................
4. Upaya Yang Telah Dilakukan :
.
5. Operasi Yang Pernah Dilakukan :
.
C. PEMERIKSAAN FISIK
1. Keadaan umum
2. Tanda tanda vital
Suhu : .. C
Nadi : ....... X / Mnt
Respirasi : .. X / Mnt
Tekanan Darah : .................. mmHg
Catatan
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3. Body system (review of system
a. Pernafasan (B1 / Breathing)
..........................................................................................................................................
..........................................................................................................................................
b. Cardiovaskuler (B2 / Bleeding)
..........................................................................................................................................
..........................................................................................................................................
c. Persyarafan (B3 / Brain)
..........................................................................................................................................
..........................................................................................................................................

d. Perkemihan Eliminasi uri (B4 / Bladder)

..........................................................................................................................................
..........................................................................................................................................
e. Pencernaan Eliminasi alvi (B5 / Bowel)
..........................................................................................................................................
..........................................................................................................................................
f. Tulang otot integument (B6 / Bone)
..........................................................................................................................................
..........................................................................................................................................
g. Sistem indokrin
..........................................................................................................................................
..........................................................................................................................................
h. Reproduksi
..........................................................................................................................................
..........................................................................................................................................
i. Psikososial
..........................................................................................................................................
..........................................................................................................................................
j. Spiritual
..........................................................................................................................................
..........................................................................................................................................

D. PEMERIKASAAN PENUNJANG
.
........
...
.......................................................................................................................................................
..................................
E. ANALISA DATA PRE OPERASI

S E P

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F. DIAGNOSA KEPERAWATAN
..............................................................................................................................
..............................................
.
G. INTERVENSI
1. Tujuan :
.................................................................................................................................................
.....................
2. Kriteria Hasil :
.
.......................
.................................................................................................................................................
3. Intervensi:
.
.................................................................................................................................................
.................................................................................................................................................
......................
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.................................................................................................................................................
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............................

H. IMPLEMENTASI
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....................................................
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I. EVALUASI
.
.
.

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.
..
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INTRA OPERASI

1. Operasi jam : . WIB s/d jam WIB

Operator :
Keadaan umum
.........
3. Tanda tanda vital
Suhu : .. C
Nadi : ....... X / Mnt
Respirasi : .. X / Mnt
Tekanan Darah : .................. mmHg
4. Catatan operasi
............................
.......................................
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5. Instrumen
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POST OPERASI

1. Operasi jam : . WIB s/d jam WIB

2. Keadaan Umum :
..
..
......
3. Tanda tanda vital
S : . C N : .. x/mnt
R : . x/mnt Tek. Darah : .mmHg
4. Catatan
............................
.......................................
....................
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.
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..

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A. ANALISA DATA POST OPERASI

S E P

B. DIAGNOSA KEPERAWATAN
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C. INTERVENSI
Tujuan
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Kriteria Hasil
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Intervensi
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D. IMPLEMENTASI
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E. EVALUASI
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Tanggal : ........................ Tanda Tangan

Nama Perawat : ........................

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