FORMAT LAPORAN KASUS

KAMAR OPERASI
Nama Mahasiswa
Tempat Praktik
Hari/Tanggal
Pembimbing

: Reka Mardiana
: Ruang OK Lt.3 RSUD Koja
:
: Ns.Ai Siti Sutilah, S.Kep

A. Identitas Pasien
Nama Pasien
:........................................................................................................
Usia
:...............................................................................................
.........
Agama
:...............................................................................................
.........
Diagnosa Medis
:........................................................................................................
B. Asuhan Keperawatan
1. Fase Preoperasi
a. Jenis Operasi

Cito

Elektif

b. Tindakan operasi
:........................................................................................................
c. Status Puasa
:........................................................................................................
d. Surat Izin Operasi
:........................................................................................................
e. Riwayat Alergi

Ya

Tidak

Jika menderita alergi jelaskan jenis alerginya :

...........................................................................................................................
............
f.

Pemeriksaan Diagnostik dan hasilnya

HB

:..........................(.........................)

HT

:..........................(.........................)

Trombosit:..........................(.........................)
Leukosit :..........................(.........................)
g. Tanda-tanda vital
TD
:.........................mmHg
:........................kali/menit
Nadi

:.........................kali/menit

2. Fase Intraoperasi

RR
Suhu :........................C

a. Status ASA
:...............................................................................
b. Jenis Anastesi
:...............................................................................
c. Obat Anastesi yang digunakan
:...............................................................................
d. Pendarahan
.......

:........................................................................

e. Cairan IV Line
:...............................................................................
f.

Jenis Sayatan
:...............................................................................

3. Fase Postoperasi
a. Post Anastesia Score
:...................................................................
b. Tanda-tanda vital

TD
:.........................mmHg
:........................kali/menit
Nadi

:.........................kali/menit

RR
Suhu :........................C

c. Status bersihan jalan nafas dan pola nafas

:......................................................
d. Peristaltik usus
:...................................................................
e. Ekstremitas
:...................................................................