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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN


STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

FORMAT ASKEP PERIOPERATIF


I. PENGKAJIAN
IDENTITAS
Nama (inisial) :.....................................................................................................
No. RM :.....................................................................................................
Usia :.....................................................................................................
Jenis Kelamin :.....................................................................................................
Alamat :.....................................................................................................
Diagnosa medis :.....................................................................................................
Tindakan operasi :.....................................................................................................

A. PRE OPERASI
1) Persiapan operasi
a. Informed consent : ada/ tidak
b. Sedia darah : ya/ tidak
Jenis darah :.......................................
Jumlah :...................................... cc
c. Skeren : ya/ tidak
d. Baju operasi : ya/ tidak
e. Lokasi operasi :......................................
f. Riwayat alergi/asma :......................................
g. Saturasi O2 pre operasi :........................
h. Kesulitan bernafas :........................
i. Bleeding :........................
j. Persiapan operasi : ( ) puasa ( ) cukur ( ) radiologi
( ) EKG ( ) USG ( ) lainnya :...........
2) Data
DS :
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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

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DO : (Termasuk di dalamnya pemeriksaan TTV, pemeriksaan penunjang)


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Kesadaran :.................................................................................................................
TD :.......................mmHg
RR :.......................x/m
HR :......................x/m
Pemeriksaan penunjang :
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B. INTRA OPERASI
DS :
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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

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DO :
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Antibiotik profilaksis :....................................................................................................
Jenis anastesi :
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Efek anastesi : ( sekresi lendir meningkat, reflek batuk)


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Kelengkapan Tim Operasi : ( ) Operator ( ) asisten ( ) scrabners
( ) sirkulerners

Tanda atau lokasi tindakan operasi :


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Sianosis :......................................
Suara nafas ngorok :......................................
Posisi saat pembedahan :.....................................
Suhu tubuh pasien :...............oC
Keadaan luka sayat operasi (lebar luka..................cm)
lama pembedahan :......................................
Perdarahan :.......................................
Urine :.......................................
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

Terpasang alat infasif : NGT/ IV line/ chateter urin


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Amati perubahan TTV setiap 15 menit sekali
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C. POST OPERASI
DS :
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DO :
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Monitor TTV (TD, RR, HR, suhu) dan kesadaran tiap 15 menit :
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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

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Saturasi oksigen post operasi :...........................
Penggunaan oksigen :...........................
Monitor tetesan infus :...........................
Posisi pasien :...........................
Spesimen (ada/ tidak) :...........................
Skore : ( ) Steward score ( ) Aldrete score
( ) Bromage score

ANALISA DATA
NO. DATA PROBLEM ETIOLOGI
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

NO. DATA PROBLEM ETIOLOGI


PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

NO. DATA PROBLEM ETIOLOGI

PRIORITAS MASALAH KEPERAWATAN :


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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

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PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

RENCANA ASUHAN KEPERAWATAN


Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

Diagnosa Keperawatan :
TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

IMPLEMENTASI DAN EVALUASI


DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

IMPLEMENTASI DAN EVALUASI


DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018

IMPLEMENTASI DAN EVALUASI


DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI PARAF EVALUASI
PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN
STASE KEPERAWATAN GADAR KRITIS
TAHUN 2018