ASUHAN KEPERAWTAN PERIOPERATIF

PADA PASIEN DENGAN………………………………………

DI OK SENTRAL/IBS RSUD ULIN

OLEH:

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BANJARMASIN
2015
 LEMBAR PENGESAHAN

NAMA MAHASISWA :.......................................................................................................................

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JUDUL ASKEP :.......................................................................................................................

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BANJARMASIN,.....................................................

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PRESEPTOR AKADEMIK PRESEPTOR KLINIK

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 PEMERINTAH PROVINSI KALIMANTAN SELATAN
RUMAH SAKIT UMUM DAERAH ULIN
INSTALASI BEDAH SENTRAL
Jl. A. Yani No. 43 Telp ( 0511 ) 252180 ext.5212
BANJARMASIN

ASUHAN KEPERAWATAN PERIOPERATIF

I. PENGKAJIAN

A. PRE OPERASI/PRE MEDIKASI

1. Serah terima pasien
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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

Pemeriksaan Penunjang: Lab Radiologi EKG Darah

Pre medikasi
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4. Data Tambahan
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B. INTRA OPERASI
1. Kelengkapan Tim Operasi
Bedah :……………………………… Anestesi :………………………Jenis Anestesi……….
2. Tanda daerah operasi: Lokasi………………………………Gambar……………………….
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
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9. Pemeriksaan kelengkapan
NO JENIS SEBELUM OP SELAMA OP SETELAH OP
1. KASA
2. JARUM
3. INSTRUMEN

10. Pemeriksaan cairan/jaringan tubuh: ada tidak ada

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11. Data Tambahan :
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C. POST OPERASI/PASCA ANESTESI
1. Air way
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2. Breathing
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3. Cirkulasi
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4. Observasi RR
Steward Scor Aldrete Scor Bromage Scor
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5. Serah terima pasien
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6. Data Tambahan :
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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. RENCANA ASUHAN KEPERAWATAN
A. PRE OPERASI
NO DIAGNOSA TUJUAN INTERVENSI IMPLEMENTASI EVALUASI
 B. INTRA OPERASI
NO DIAGNOSA TUJUAN INTERVENSI IMPLEMENTASI EVALUASI
 C. POST OPERASI
NO DIAGNOSA TUJUAN INTERVENSI IMPLEMENTASI EVALUASI