PROGRAM STUDI PENDIDIKAN NERS

STIKES SURYA MITRA HUSADA KEDIRI

PROGRAM PENDIDIKAN PROFESI NERS
ALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama Mahasiswa : ...

NIM :

FORMAT RESUME KAMAR OPERASI

Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jenis Operasi : Diagnosa Medis :
Jam Operasi :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Gol. Darah :
4. Suku/ Bangsa :
5. Agama :
6. Pendidikan :
7. Pekerjaan :
8. Alamat :
9. Sumber Biaya :

KELUHAN UTAMA
Keluhan utama :


RIWAYAT PENYAKIT SEKARANG
Riwayat Penyakit Sekarang :
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OBSERVASI DAN PEMERIKSAAN FISIK
Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma
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STIKes Surya Mitra Husada Kediri

 ANALISIS DATA PRE OP.

Hari/
MASALAH
Tgl/ DATA ETIOLOGI
KEPERAWATAN
Jam

DIAGNOSA KEPERAWATAN PRE OP :

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STIKes Surya Mitra Husada Kediri

 RENCANA INTERVENSI PRE OP.

Hari/ NOC NIC

No. DIAGNOSA KEPERAWATAN
Tgl/ Jam (Nursing Outcome Classification) (Nursing Intervention Classification)

STIKes Surya Mitra Husada Kediri

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift

STIKes Surya Mitra Husada Kediri

 PERSIAPAN PASIEN OPERASI :
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PERSIAPAN ALAT

Alat streril Jumlah Alat Non Steril Jumlah

Pre op. Post op. Pre op. Post op.
a. Tidak Habis Pakai

b. Habis Pakai

STIKes Surya Mitra Husada Kediri

PELAKSANAAN OPERASI :
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STIKes Surya Mitra Husada Kediri

 EVALUASI
Keadaan Umum :
a. Kesadaran : Compos Mentis Apatis Somnolen Sopor Koma
b. GCS :

Observasi Tanda-tanda Vital :

Tekanan darah Respiratori rate

Menit ke- Nadi (kali/menit) Suhu (0C)
(mmHg) (kali/menit)

Balance Cairan :

Menit Ke- Intake Jumlah (cc) Output Jumlah (cc)

Total

Tanggal : .

Mahasiswa

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STIKes Surya Mitra Husada Kediri