RESUME KEPERAWATAN KLIEN……………….

DENGAN………………………
DIRUANG INSTALASI BEDAH SENTRAL
RSUD KARANGANYAR

A. ASUHAN KEPERAWATAN PERIOPERATIF

1. Identitas Klien
a. Nama : ………………………………
b. JenisKelamin : ………………………………
c. Umur : ………………………………
d. Agama : ………………………………
e. Suku/Bangsa : ………………………………
f. Pendidikan : ………………………………
g. Pekerjaan : ………………………………
h. Alamat : ………………………………
i. Tgl pengkajian : ………………………………
2. Riwayat Kesehatan
a. Dx Medis : ………………………………
b. Rencana Operasi : ………………………………
c. Jenis Anastesi : ………………………………
d. Status Kesehatan Saat ini : ………………………………
e. Riwayat penyakit sebelumnya : ………………………………
f. Riwayat penyakit keturunan : ………………………………

B. PROSES KEPERAWATAN
1. FASE PRE OPERASI
a. PENGKAJIAN
 Kelengkapan Administrasi
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 Obat Premedikasi
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 Pengkajian 6 B
 B1 (breath) pernafasan
Bentuk dada : ………………….
RR : …………..x/menit
Pola nafas : …………………..
Suara nafas : …………………..
Batuk : …………………..
Retraksi otot bantu nafas : …………………..
Alat bantu nafas : …………………..
 B2 (blood) kardiovaskuler
Irama jantung : …………………..
Nyeri dada : …………………..
Bunyi jantung : …………………..
Akral : …………………..
Nadi : …………..x/menit
 B3 (brain) saraf
Penglihatan (mata) : …………………..
Pendengaran (telinga) : …………………..
Penciuman (hidung) : …………………..
Pengecap (lidah) : …………………..
Kesadaran : …………………..
 B4 bladder (perkemihan)
Kebersihan : …………………..
Produksiurin : …………………..
 B5 bowel (pencernaan)
Mulut : …………………..
Mukosa : …………………..
 B6 bone (muskuloskeletal)
Kemampuan pergerakan sendi : …………………..
Kondisi tubuh : …………………..
b. ANALISA DATA
Nama Klien : ……………………… No. Register : ………………………..
Umur : ……………………… Diagnosa Medis : ………………………..
DATA FOKUS ETIOLOGI PROBLEM
c. DIAGNOSA KEPERAWATAN
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d. INTERVENSI
NO DX KEPERAWATAN TUJUAN INTERVENSI
e. IMPLEMENTASI
TGL JAM NO.DX IMPLEMENTASI RESPON TTD
f. EVALUASI
TGL/JAM DX KEPERAWATAN EVALUASI TTD
2. TAHAP INTRA OPERASI
a. PENGKAJIAN
1) Persiapan perawat
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2) Persiapan pasien
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3) Prosedur operasi
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4) Pengakhiran anastesi dan pembedahan
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5) Pengkajian 6 B
 B1 (breath) pernafasan
Bentukdada : ………………….
RR : …………..x/menit
Pola nafas : …………………..
Suaranafas : …………………..
Batuk : …………………..
Retraksi otot bantu nafas : …………………..
Alat bantu nafas : …………………..
 B2 (blood) kardiovaskuler
Irama jantung : …………………..
Nyeri dada : …………………..
Bunyi jantung : …………………..
Akral : …………………..
Nadi : …………..x/menit
 B3 (brain) saraf
Penglihatan (mata) : …………………..
Pendengaran (telinga) : …………………..
Penciuman (hidung) : …………………..
Pengecap (lidah) : …………………..
Kesadaran : …………………..
 B4 bladder (perkemihan)
Kebersihan : …………………..
Produksi urin : …………………..
 B5 bowel (pencernaan)
Mulut : …………………..
Mukosa : …………………..
 B6 bone (muskuloskeletal)
Kemampuan pergerakan sendi : …………………..
Kondisi tubuh : …………………..
b. ANALISA DATA
Nama Klien : ……………………… No. Register : ………………………..
Umur : ……………………… Diagnosa Medis : ………………………..
DATA FOKUS ETIOLOGI PROBLEM
c. DIAGNOSA KEPERAWATAN
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d. INTERVENSI
NO DX KEPERAWATAN TUJUAN INTERVENSI
e. IMPLEMENTASI
TGL JAM NO.DX IMPLEMENTASI RESPON TTD
f. EVALUASI
TGL/JAM DX KEPERAWATAN EVALUASI TTD
3. TAHAP POST OPERASI
a. Pengkajian 6 B
 B1 (breath) pernafasan
Bentuk ndada : ………………….
RR : …………..x/menit
Pola nafas : …………………..
Suara nafas : …………………..
Batuk : …………………..
Retraksi otot bantu nafas : …………………..
Alat bantu nafas : …………………..
 B2 (blood) kardiovaskuler
Irama jantung : …………………..
Nyeri dada : …………………..
Bunyi jantung : …………………..
Akral : …………………..
Nadi : …………..x/menit
 B3 (brain) saraf
Penglihatan (mata) : …………………..
Pendengaran (telinga) : …………………..
Penciuman (hidung) : …………………..
Pengecap (lidah) : …………………..
Kesadaran : …………………..
 B4 bladder (perkemihan)
Kebersihan : …………………..
Produksi urin : …………………..
 B5 bowel (pencernaan)
Mulut : …………………..
Mukosa : …………………..
 B6 bone (muskuloskeletal)
Kemampuan pergerakan sendi : …………………..
Kondisi tubuh : …………………..
b. Subjektif
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c. Objektif
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d. ANALISA DATA
Nama Klien : ……………………… No. Register : ………………………..
Umur : ……………………… Diagnosa Medis : ………………………..
DATA FOKUS ETIOLOGI PROBLEM
e. DIAGNOSA KEPERAWATAN
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f. INTERVENSI
NO DX KEPERAWATAN TUJUAN INTERVENSI
g. IMPLEMENTASI
TGL JAM NO.DX IMPLEMENTASI RESPON TTD
h. EVALUASI
TGL/JAM DX KEPERAWATAN EVALUASI TTD