FORMAT RESUME KASUS

DI KAMAR OPERASI (Instalansi Bedah Sentral)

LAPORAN PRAKTIK PROFESI

ASUHAN KEPERAWATAN PADA .................... DENGAN .........................................
DI RUANG O.K RSUP SANGLAH DENPASAR
PADA TANGGAL ..................................................................

Nama Mahasiswa : ...................................................................................................

NIM : ...................................................................................................
Tanggal Praktek : ...................................................................................................

1. Identitas Klien
Nama : ..................................................................................................
Jenis Kelamin : ..................................................................................................
Umur : ..................................................................................................
Status : ..................................................................................................
Agama : ..................................................................................................
Tanggal masuk : ..................................................................................................
Tanggal pengkajian : ..................................................................................................
Riwayat Kesehatan : ..................................................................................................
Dx Medis : ..................................................................................................
Rencana Operasi : ..................................................................................................

2. Proses Keperawatan
a. Pre Operasi (Ruang Persiapan Operasi)
1) Data Fokus
Data Subyektif
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Data Obyektif
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2) Diagnosa Keperawatan/Masalah Kolaborasi

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3) Intervens/ implementasi

Hari/ Tgl No. Intervensi Pelaksanaan Ttd

Dx

4) Evaluasi
Hari/ Tgl No.Dx Evaluasi Ttd

b. Intra Operasi (Ruang Operasi)

1) Laporan Intra Operasi
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 Data Subyetif
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Data Obyektif
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2) Diagnosa Keperawatan/Masalah Kolaborasi
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3) Intervensi/Implementasi
Hari/ Tgl No. Intervensi Pelaksanaan Ttd
Dx

4) Evaluasi
Hari/ Tgl No.Dx Evaluasi Ttd
c. Post Operasi (Recovery Room)
1) Data Fokus
Data Subyetif
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Data Obyektif
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2) Diagnosa Keperawatan/Masalah Kolaborasi
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3) Intervensi/Implementasi
Hari/ Tgl No. Intervensi Pelaksanaan Ttd
Dx

4) Evaluasi
Hari/ Tgl No.Dx Evaluasi Ttd