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  • Askep Perioperatif

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    ASKEP PERIOPERATIF

    Judul Asli

    ASKEP PERIOPERATIF

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    ASKEP PERIOPERATIF

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    3 tayangan10 halaman

    Askep Perioperatif

    Diunggah oleh

    Anonymous Ly9kyb7FX
    ASKEP PERIOPERATIF

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai XLSX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 10

    PEMERINTAH KABUPATEN SUMENEP No.

    RM :
    RSUD Dr. H. MOH. ANWAR Nama :
    EK
    Jl. Dr. Cipto No. 42 Telp. (0328) 662129, 662494,662979 Jenis Kelamin :
    SUM AR

    SUMENEP Kode Pos 69417 Umur :


    PRE OPERATIF
    Tanggal / Jam : TINDAKAN KEPERAWATAN
    PENGKAJIAN DIAGNOSIS KEPERAWATAN RENCANA TINDAKAN IMPLEMENTASI EVALUASI
    1. Breathing (B1)
    Spontan dibantu
    RR : x/mnt
    Saturasi O2 :
    2. Blood (B2)
    BP : mmHg
    HR : x/mnt
    t:
    canula IV
    3. Brain (B3)
    Kesadaran
    CM Apatis
    Deliri Somnolen
    Supor Koma
    Status Emosi
    cemas tenang
    Penilaian Nyeri
    akut kronis derajat : ...

    lokasi :
    4. Bladder (B4)
    kateter :
    urine : cc
    lain :
    5. Bowel (B5)
    BB : Kg TB: cm
    puasa
    mual-muntah
    distensi
    6. Bone dan Integumen
    integritas kulit : utuh
    tidak
    fraktur : tidak tertutup
    terbuka
    PEMERINTAH KABUPATEN SUMENEP No. RM : ..............................................
    RSUD Dr. H. MOH. ANWAR Nama : ..............................................

    Jl. Dr. Cipto No. 42 Telp. (0328) 662129, 662494,662979 Jenis Kelamin : ..............................................
    EK
    SUM AR

    SUMENEP Kode Pos 69417 Umur : ..............................................


    ASUHAN KEPERAWATAN PERIOPERATIF DI KAMAR BEDAH
    PENGKAJIAN PRE OPERATIF Jam : ................................... Tanggal
    Breathing Blood Brain
    spontan BP : .................. mmHg a. Kesadaran :
    dibantu : ............................. HR : .................. X/mnt GCS : ......./......./......
    RR : .......... x/mnt t : .................. C b. Status Emosi
    SPO2 : .......... % infus : .............................. Cemas
    Lain - lain : ............................... Lain - lain : ............................... c. Penilaian Nyeri
    .................................................. .................................................. Akut
    .................................................. .................................................. Lokasi : ..............................
    .................................................. ..................................................
    .................................................. ..................................................
    .................................................. .................................................. Lain - lain : ...............................
    Bladder Bowel Bone dan Skin
    Kateter : ............... tgl : ........ BB : .......... Kg TB : ........ Cm a. Bone
    Distensi Gastric Tube Patah
    Jumlah urine : ................. cc Puasa
    Konsistensi : .......................... Mual muntah Lokasi : ............................
    Lain - lain : .............................. Distensi b. Skin (integritas)
    ................................................. Sulit menelan Utuh
    ................................................. Lain - lain : ................................ Luka bakar derajat : ...............................
    ................................................. ................................................. Lokasi : ..................................................
    ................................................. ................................................. Lain - lain : .....................................................
    ................................................. ................................................. ......................................................................

    DIAGNOSIS RENCANA IMPLEMENTASI JAM EVALUASI


    Nyeri b.d : ....... Laksanakan orientasi Perkenalan diri ......... ................................
    ........................... Cek kelengkapan dokumen Orientasi preoperasi ......... ................................
    ........................... Lakukan Health education Timbang terima ......... ................................
    Cemas b.d : ....... Observasi vital sign dan pasien, kelengkapan ................................
    ........................... keadaan umum Informasi proses, ......... ................................
    ........................... Kolaborasi pemberian obat .... dan lingkungan ................................
    Kurang .............................................. Observasi vital sign, ......... ................................
    pengetahuan b.d Kolaborasi pemberian anti- keadaan umum ................................
    ........................... biotika .................................. Memberikan O2 ... ................................
    ........................... Pertahankan cairan .............. ............................. ......... ................................
    ........................... Pasang oksigen tambahan .. Memasang infus ......... ................................
    ........................... ............................................ Memberikan posisi ................................
    ........................... Kolaborasi pemasangan ......... nyaman ................ ......... ................................
    ........................... .............................................. Memberikan Obat ................................
    ........................... Berikan posisi nyaman ............................. ......... ................................
    ........................... Siapkan obat / mesin anestesi ............................. ......... ................................
    ........................... Ajarkan pain managements ............................. ......... ................................
    ........................... Pantau efek premedikasi Menyiapkan mesin, ................................
    ........................... Siapkan alat / bahan operasi alat, obat anestesi ......... ................................
    ........................... Lakukan sign in Mengajarkan teknik ................................
    ........................... .............................................. ............................. ......... ................................
    ........................... .............................................. Memonitor efek ................................
    ........................... .............................................. obat premedikasi ......... ................................
    ........................... .............................................. Menyiapkan alat, ................................
    ........................... .............................................. bahan operasi ......... ................................
    ........................... .............................................. Melakukan sign in ......... ................................
    ........................... .............................................. ............................ ......... ................................
    ........................... .............................................. ............................ ......... ................................
    ........................... .............................................. ............................ ......... ................................
    ........................... .............................................. ............................ ......... ................................
    PENGKAJIAN INTRA OPERATIF Tanggal
    Jam masuk OK : ........................ Jam mulai tindakan : ................ Nama tindakan : ......................................
    Jenis anestesi : ........................ Jam selesai Tindakan : ................ .......................................
    Jam mulai anestesi : ................. Jam selesai anestesi : ................
    Breathing Blood Brain
    spontan Stabil Tidak : .................. mmHg a. Kesadaran :
    dibantu : ............................. HR : .................. X/mnt GCS : ......./......./......
    OPA LMA ETT Stabil Tidak stabil b. Status Emosi
    Ukuran : ............................. infus : .............................. Cemas
    RR : .......... x/mnt Lain - lain : ............................... c. Penilaian Nyeri
    SPO2 : .......... % .................................................. Akut lokasi : .............................
    Lain - lain : ............................... ..................................................
    .................................................. ..................................................
    .................................................. .................................................. Lain - lain : ...............................
    Bladder Bowel Bone dan Skin
    Kateter : ............... tgl : ........ BB : .......... Kg TB : ........ Cm a. Bone
    Distensi Gastric Tube Patah
    Jumlah urine : ................. cc Distensi Lokasi : ............................
    Konsistensi : .......................... Mual muntah b. Skin (integritas)
    Lain - lain : .............................. Distensi Utuh
    ................................................. Lain - lain : ................................ Lain - lain : .....................................................
    ................................................. ................................................. ......................................................................

    DIAGNOSIS RENCANA IMPLEMENTASI JAM EVALUASI


    Bersihan jalan Siapkan lingkungan operasi Menyiapkan lingkung- ................................
    napas inefektif b.d Siapkan pasien di meja operasi an operasi ............... ......... ................................
    ........................... Berikan posisi sesuai prosedur Memposisikan pasien : ................................
    ........................... Observasi vital sign dan ............................ ......... ................................
    Nyeri b.d : ....... keadaan umum Mengobservasi vital ......... ................................
    ........................... Kolaborasi pemberian obat .... sign, keadaan umum ................................
    ........................... .............................................. ............................. ......... ................................
    Risiko defisit Siapkan instrumen dan bahan Memberikan Obat ................................
    volume cairan bahan habis pakai operasi ............................. ......... ................................
    b.d .................... Pertahankan cairan .............. ............................. ......... ................................
    ........................... Pasang oksigen tambahan .. Memasang sabuk pe- ................................
    ........................... ............................................ ngaman ......... ................................
    Risiko hipotermi Pasang diathermi dan plat, Menyiapkan linen, ................................
    b.d .................... awasi kondisi kulit dan alat instrumen, alkes ......... ................................
    ........................... Lakukan skin preparations Maintenance cairan ................................
    ........................... Laksanakan standar pre- ............................. ......... ................................
    Risiko injuri cautions pembedahan Memberikan O2 ... ................................
    b.d .................... Lakukan penghitungan awal ............................. ......... ................................
    ........................... Intrumen, kasa, depper Memasang plat dia- ................................
    ........................... Observasi pemakaian torniquet termi dengan benar ......... ................................
    ........................... Lakukan Time out Melakukan skin pre- ................................
    ........................... Asistensi dokter anestesi paration ......... ................................
    ........................... Monitor Intake dan output Scrubing, Gowning ................................
    ........................... Lakukan cuci luka Gloving ......... ................................
    ........................... Lakukan penghitungan akhir Menghitung kassa, ................................
    ........................... kassa, intrumen, depper instrumen, depper ......... ................................
    ........................... Lakukan sign out Melakukan time out ......... ................................
    ........................... Cek bahan spesimen Melakukan asistensi ................................
    ........................... Pasang / lepas sabuk peng- dokter anestesi ......... ................................
    ........................... aman pasien Memonitor intake- ................................
    ........................... Lakukan rawat luka output ......... ................................
    ........................... ...................................... Menghitung kassa, ................................
    ........................... ...................................... deppere, instrumen ......... ................................
    ........................... ...................................... Melakukan sign out ......... ................................
    ........................... ...................................... Mencuci Luka ......... ................................
    ........................... ...................................... ............................ ......... ................................
    ........................... ...................................... ............................ ......... ................................
    PENGKAJIAN POST OPERATIF Jam masuk RR : ............. Jam/Tanggal Keluar RR : ......./..................
    Breathing Blood Brain
    spontan BP : .................. mmHg a. Kesadaran :
    dibantu : ............................. HR : .................. X/mnt GCS : ......./......./......
    RR : .......... x/mnt t : .................. C b. Status Emosi
    SPO2 : .......... % infus : .............................. Cemas
    Lain - lain : ............................... Lain - lain : ............................... c. Penilaian Nyeri
    .................................................. .................................................. Lokasi : ..............................
    .................................................. ..................................................
    .................................................. ..................................................
    .................................................. .................................................. Lain - lain : .....................................................
    .................................................. .................................................. ......................................................................
    Bladder Bowel Bone dan Skin
    Kateter : ............... tgl : ........ BB : .......... Kg TB : ........ Cm a. Bone
    Distensi Gastric Tube Patah
    Jumlah urine : ................. cc Puasa Lokasi : ..................................
    Konsistensi : .......................... Mual muntah Implan Gips
    Lain - lain : .............................. Distensi b. Skin (integritas)
    ................................................. Sulit menelan Utuh
    ................................................. Lain - lain : ................................ Lain - lain : .....................................................
    ................................................. ................................................. ......................................................................
    ................................................. ................................................. ......................................................................
    DIAGNOSIS RENCANA IMPLEMENTASI JAM EVALUASI
    Bersihan jalan Lakukan timbang terima Timbang terima ......... ................................
    napas inefektif b.d Pertahankan jalan napas paten Melakukan suction ......... ................................
    ........................... Pasang oksigen tambahan tiap .... ................................
    ........................... Pertahankan cairan .............. Memberikan O2 ... ................................
    Nyeri b.d : ....... Pantau skala nyeri ............................. ......... ................................
    ........................... Berikan posisi nyaman Maintenance cairan ................................
    ........................... Observas kondisi luka operasi .............................. ......... ................................
    Hipotermia b.d Observasi vital sign dan Memantau skala ................................
    ........................... keadaan umum nyeri, kemampuan ................................
    ........................... Kolaborasi pemberian obat pasien mengatasinya ......... ................................
    ........................... Pantau Balance cairan Memberikan posisi ................................
    Risiko defisit Ciptakan lingkungan nyaman ............................... ......... ................................
    volume cairan b.d Kolaborasi pemasangan ......... Mengobservasi ................................
    ........................... .............................................. kondisi luka operasi ......... ................................
    ........................... Pertahankan suhu lingkungan Mengobservasi vital ................................
    ........................... nyaman sign, keadaan umum ......... ................................
    Risiko injuri b.d Jaga keselamatan pasien Memberikan obat ................................
    ........................... Ajarkan teknik mengurangi ............................. ......... ................................
    ........................... nyeri ............................. ......... ................................
    ........................... Lakukan Health education ............................. ......... ................................
    Cemas b.d : ....... .............................................. Memonitor intake ................................
    ........................... .............................................. output : ............. ......... ................................
    ........................... .............................................. ............................ ......... ................................
    Kurang .............................................. Memberikan selimut ................................
    pengetahuan b.d .............................................. hangat ......... ................................
    ........................... .............................................. Memasang restraint ......... ................................
    ........................... .............................................. Mengajarkan teknik ................................
    ........................... .............................................. relaksasi nyeri ......... ................................
    ........................... .............................................. Health education ......... ................................
    ........................... .............................................. ............................ ......... ................................
    ........................... .............................................. ............................ ......... ................................

    INTRA OPERATIF
    PERAWAT PRE OPERATIF POST OPERATIF
    Sirkuler Instrumen Anestesi
    Nama ................................... .............. ................... ........................... ...........................................
    Tanda tangan ................................... .............. ................... ........................... ...........................................
    : ..............................................
    : ..............................................
    : ..............................................
    : ..............................................
    AWATAN PERIOPERATIF DI KAMAR BEDAH
    : ....................

    Tenang

    Kronis
    : ..............................

    Lain - lain : ...............................

    Terbuka
    Tertutup
    Lokasi : ............................

    Tidak
    Luka bakar derajat : ...............................
    Lokasi : ..................................................
    Lain - lain : .....................................................
    ......................................................................

    EVALUASI
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    ................................
    : ..............
    Nama tindakan : ......................................
    .......................................

    Terinduksi

    Tenang

    lokasi : .............................

    Lain - lain : ...............................

    Tidak
    Lokasi : ............................

    Tidak
    Lain - lain : .....................................................
    ......................................................................

    EVALUASI
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    Jam/Tanggal Keluar RR : ......./..................

    Tenang

    : ..............................

    Lain - lain : .....................................................


    ......................................................................

    Tidak
    Lokasi : ..................................
    Fiksasi Luar

    Tidak
    Lain - lain : .....................................................
    ......................................................................
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    EVALUASI
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    POST OPERATIF

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