PROGRAM STUDI ILMU KEPERAWATAN DAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN SUAKA INSAN

STASE KEPERAWATAN GADAR KRITIS
TAHUN 2019

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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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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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 :.......................................
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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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
NO. DATA PROBLEM ETIOLOGI
PRIORITAS MASALAH KEPERAWATAN :
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RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan : ...................................................................................................................................................................................
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TUJUAN DAN KRITERIA
INTERVENSI RASIONAL
HASIL
IMPLEMENTASI DAN EVALUASI
DIAGNOSA EVALUASI
JAM IMPLEMENTASI PARAF
KEPERAWATAN