KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI PENDIDIKAN PROFESI NERS

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA

LAPORAN ASUHAN KEPERAWATAN PERIOPERATIVE

A. Asuhan Keperawatan Preoperatif

1. Identitas
Nama : _________________________________
Umur : _________Tahun
Status : _________________________________
Agama : _________________________________
Tanggal masuk : _________________________________
Tanggal pengkajian : _________________________________
Sumber informasi : _________________________________
2. Pengkajian
a. Riwayat kesehatan
Diagnosa medis : _________________________________
Jenis operasi : _________________________________
Jenis anastesi : _________________________________
Keluhan utama :
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Riwayat penyakit sekarang :
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Riwayat penyakit dahulu :

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b. Pemeriksaan laboratorium :
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c. Persiapan operasi :
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d. Persiapan saat di ruang penerimaan :
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 3. Analisa data

Data Diagnosa Tujuan Intervensi

4. Implementasi dan Evaluasi

Hari/tangga Diagnosa Implementasi Evaluasi

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B. Asuhan Keperawatan Intraoperative
1. Pengkajian
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Persiapan perawat
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Persiapan pasien
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Prosedur operasi
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2. Analisa data

Data Diagnosa Tujuan Intervensi

 3. Implementasi dan Evaluasi

Hari/tangga Diagnosa Implementasi Evaluasi

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Hari/tangga Diagnosa Implementasi Evaluasi
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C. Asuhan Keperawatan Post Operatif

1. Pengkajian
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 2. Analisa data

Data Diagnosa Tujuan Intervensi

3. Implementasi dan Evaluasi

Hari/tangga Diagnosa Implementasi Evaluasi

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Hari/tangga Diagnosa Implementasi Evaluasi
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