I.

IDENTITAS PASIEN DAN PENANGGUNG JAWAB

1. IDENTITAS PASIEN
Nama :
Usia :
Jenis kelamin :
No. rekam medic :
Diagnosa medis :
Tanggal masuk RS :
Tanggal Pengkajian:
Alamat :
2. IDENTITAS PENENGGUNG JAWAB
Nama :
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Hub. Dg klien :
II. PENGKAJIAN
1. KELUHAN UTAMA
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2. RIWAYAT KESEHATAN
a. Riwayat kesehatan sekarang
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b. Riwayat kesehatan dahulu
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 c. Riwayat kesehatan keluarga
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d. Pola Aktifitas Sehari- hari

No Jenis Aktifitas Di Rumah Di RS

1 Nutrisi

2 Eliminasi BAB

BAK

3 Istirahat /tidur

4 Ambulasi

5 Kebersihan diri

e. Pengkajian fisik
 Sistem respirasi dan oksigenisasi
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  Sistem kardiovaskuler
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 Sistem gastrointetinal
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 Sistem neurologi
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 Sistem skeletal
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 Sistem urogenital
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 Sistem integumen
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f. Hasil pemeriksaan diagnostik
A. pre Operasi

Dignosa :
Informed consent :

Persiapan kamar bedah

1. Alat operatif steril
2. Meja/tempat tidur operasi
3. Monitor
4. Standart infuse
5. Suction
2. Pelaksanaan pembedahan
- Operator :
- Asisten/Instrument :
- Perawat onloop :
- Anastesi :
- Penata :
- Jenis anastesi :
- Obat anastesi :
3. Persiapan instrument
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B. Intra Operatif

Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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Pukul
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C. Post Operatif
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TTV:
Tekanan darah :
Suhu :
Nadi :
RR :
SPO2 :
Do :
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DS :

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Instruksi dokter bedah:

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Instruksi dokter anastesi :

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III. Analisa data

Data Etiologi Probblem

IV.RENCANA ASUHAN KEPERAWATAN

No. Diagnosa Tujuan Intervensi Rasional

Keperawatan
V. IMPLEMENTASI

Hari / No. DP Implementasi Evaluasi

tanggal
VI. EVALUASI

nO Hari/tanggal Diagnosa Keperawatan Evaluasi

 LAPORAN KASUS
ASUHAN KEPERAWATAN PASIEN ...............DENGAN GANGGUAN
SISTEM .............................:.........................................................
DI RUANG INSTALASI BEDAH SENTRAL RSUD KOTA BANDUNG

NAMA :................................
NPM :....................................

PROGRAM PROFESI NERS

STASE KEPERAWATAN MEDICAL BEDAH
SEKOLAH TINGGI ILMU KESEHATAN BHAKTI KENCANA
BANDUNG
2018