PROGRAM PENDIDIKAN PROFESI

NERS STIKES WIDYAGAMA

HUSADA

FORMAT PENGKAJIAN PERIOPERATIF KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa
NIM
Tempat Pengkajian
Tanggal
:
I. Identitas Klien
Nama
Umur
Jenis Kelamin
Agama
Pendidikan
Alamat

:
:
:

:
:
:
:
:
:

No.RM
:
Pekerjaan
Status Perkawinan
Tanggal MRS
Tanggal Pengkajian
Sumber Informasi

:
:
:
:
:

II. Riwayat Kesehatan

1. Keluhan utama

2. Riwayat penyakit sekarang

3. Riwayat penyakit dahulu

.
4. Diagnosa medis pada saat MRS

5. Pemeriksaan Fisik

PREOPERASI
Keluhan pada periode preoperasi:

Tanda-tanda vital:

Analisa data:
No

Data

Masalah

Penyebab

Implementasi dan Evaluasi

No

Diagnosa

Implementasi

Evaluasi

INTRA OPERASI
a. Persiapan alat dan ruangan
Alat tidak steril:

Alat Steril:

Bahan Medis Habis Pakai:

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Set yang dipakai:

Persiapan Perawat

Persiapan Pasien

.
Prosedur operasi

.
Evaluasi selama operasi

Analisa Data
No

Data

Masalah

Penyebab

Implementasi dan Evaluasi

No

Diagnosa

Implementasi

Evaluasi

POST OPERASI
Kondisi Pasien di RR
.................................................................................................................................................
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...........................................................................................

Analisa Data
No

Data

Masalah

Penyebab

Implementasi dan Evaluasi

No

Diagnosa

Implementasi

Evaluasi

Malang,

(
NIM