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
a) TTV

: TD :
RR :

b) Reaksi Fisik

mmHg

N:

x/menit

x/menit

S:

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c) Reaksi Psikologi

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d) Persiapan Operasi
:
Informed Concent/Ijin Anestesi
Puasa
Cukur
e) Pemeksaan Penunjang : Lab
f) Pre medikasi

Radiologi

EKG

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B. INTRA OPERASI
1. Kelengkapan Tim Operasi
a) Bedah :
Operator
: ......................................................................................................
Asisten Operator : ......................................................................................................
Asisten Instrumen: .......................................................................................................
Onloop
: ......................................................................................................
b) Anastesi :
Dokter Anastesi : .....................................................................................................
Asisten Anastesi : ......................................................................................................
2. Tanda daerah operasi

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

3. Kelengkapan Anestesi

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

4.
5.
6.
7.

a) Jenis Anastesi
: .....................................................................................................
b) IV Line
:......................................................................................................
c) Obat-obatan
: .....................................................................................................
Riwayat asma/alergi
:......................................................................................................
Posisi operasi
: .....................................................................................................
Rencana dilakukan tindakan :..................................................................................................
Observasi tindakan operasi :
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8. Observasi tindakan anestesi

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9. Pemeriksaan kelengkapan
Kasa
Jarum
Instrumen
10. Pemeriksaan cairan/jaringan tubuh :

Ada

Tidak ada

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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 Recovery Room
Steward Scor

Aldrete Scor

Bromage Scor

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5. Serah terima pasien
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II. ANALISA DATA
A. Pre Operasi
DATA

ETIOLOGI

MASALAH

B. Intra Operasi
DATA

ETIOLOGI

MASALAH

ETIOLOGI

MASALAH

C. Post Operasi
DATA

III. INTERVENSI, IMPLEMENTASI & EVALUASI ASUHAN KEPERAWATAN

A. PRE OPERASI
NO
.

DIAGNOSA
KEPERAWATAN

NOC

NIC

IMPLEMENTASI

EVALUASI

NO
.

B. INTRA OPERASI
DIAGNOSA
KEPERAWATAN

NOC

NIC

IMPLEMENTASI

EVALUASI

NO
.

C. POST OPERASI
DIAGNOSA
KEPERAWATAN

NOC

NIC

IMPLEMENTASI

EVALUASI