Pengkajian OK
Pengkajian OK
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
:
:
:
:
:
.
4. Diagnosa medis pada saat MRS
5. Pemeriksaan Fisik
PREOPERASI
Keluhan pada periode preoperasi:
Tanda-tanda vital:
Analisa data:
No
Data
Masalah
Penyebab
Diagnosa
Implementasi
Evaluasi
INTRA OPERASI
a. Persiapan alat dan ruangan
Alat tidak steril:
Alat Steril:
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Set yang dipakai:
Persiapan Perawat
Persiapan Pasien
.
Prosedur operasi
.
Evaluasi selama operasi
Analisa Data
No
Data
Masalah
Penyebab
Diagnosa
Implementasi
Evaluasi
POST OPERASI
Kondisi Pasien di RR
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Analisa Data
No
Data
Masalah
Penyebab
Diagnosa
Implementasi
Evaluasi
Malang,
(
NIM