Format Resume Askep Cath Lab
Format Resume Askep Cath Lab
IDENTITAS KLIEN
Nama : ............................................... No. RM : .........................................
Tgl lahir/ umur : ............................................... Status perkawinan : .........................................
Jenis kelamin : L/P*) Agama : .........................................
Alamat : ............................................... Ruang rawat/ Poli* : .........................................
............................................... Sumber informasi : .........................................
TAHAP PRA-TINDAKAN
1. Keluhan utama : ......................................................................................................................
......................................................................................................................
2. Riwayat penyakit : ( )DM ( )Jantung ( )Hipertensi ( )Lain-lain, sebutkan .......................
3. Riwayat operasi jantung (CABG) : ( )Ada, waktu:................( ) Tidak ada
4. Riwayat tindakan invasif lain (contoh: Angiografi coroner, PCI) :
( ) Ada, Tindakan :........................... waktu:................ ( ) Tidak ada
Hasil :...........................
( ) Ada, Tindakan :........................... waktu:................ ( ) Tidak ada
Hasil :...........................
5. Pemeriksaan Fisik :
TTV : TD: ......... mmHg; Nadi: ..... x/mnt; RR: .... x/mnt; suhu: .... oC
BB/TB : ......... kg/......... cm
Pemeriksaan fisik terfokus (sistem KV) :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Persiapan Tindakan
a. Diagnosa medis : ....................................................................................................
b. Rencana tindakan : ....................................................................................................
c. ASA (American Society of Anesthesiologists) classification : .......................................
d. Informed consent : ( ) Ada, tanggal : …..………………….. ( ) Tidak ada
e. Klien dipuasakan : ( ) Ya, mulai jam : ........................ ( ) Tidak
f. Lokasi akses yg akan digunakan : .......................................................................................
g. Penandaan site akses : ( ) Ya, di .................................... ( ) Tidak
h. Stress test/enilaian LVSF : ( ) Ya, hasil ................................... ( ) Tidak
i. Riwayat Alergi :
Kontras ( ) Ya ( ) Tidak
Aspirin ( ) Ya ( ) Tidak
Heparin ( ) Ya ( ) Tidak
Lateks ( ) Ya ( ) Tidak
4. Prosedur tindakan (jelaskan tahapan tindakan mulai dari desinfeksi site akses s.d. menutup luka op! )
(................................)
Analisa data & Perencanaan
Post Tindakan
Implementasi & Evaluasi
Post Tindakan