LAPORAN PRAKTIK KLINIK KEPERAWATAN

PREOPERASI

OLEH:
NAMA :
NIM :

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEPERAWATAN
PROGRAM STUDI SARJANA TERAPAN KEPERAWATAN MALANG
2020
 LEMBAR PENGESAHAN

Laporan Asuhan Keperawatan Perioperatif (Preoperasi) dengan judul:

Telah diperiksa dan dilakukan responsi dengan pembimbing institusi dan

pembimbing klinik pada:

Hari, tanggal :

Tempat:

Pembimbing Institusi Pembimbing Kinik

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 FORMAT ASUHAN KEPERAWATAN

A. PENGKAJIAN
1. Pengumpulan Data
a. Biodata
1) Nama :
2) Jenis Kelamin :
3) Umur :
4) Status Perkawinan :
5) Pekerjaan :
6) Agama :
7) Pendidikan Terakhir :
8) Alamat :
9) Tanggal MRS :

b. Diagnosa Medis
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c. Keluhan Utama (Saat Pengkajian)

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d. Riwayat Penyakit Sekarang

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e. Riwayat Kesehatan (Penyakit yang Lalu)

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f. Riwayat Kesehatan Keluarga

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g. Pola Aktivitas Sehari-hari

1) Makan dan Minum
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2) Pola Eliminasi
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 3) Pola Istirahat dan Tidur
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4) Kebersihan Diri
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h. Riwayat Psikososial
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i. Pemeriksaan Fisik
1) Keadaan Umum
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2) Tanda-Tanda Vital
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3) Pemeriksaan Kepala Leher

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4) Pemeriksaan Integumen
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5) Pemeriksaan Dada Thorax

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6) Pemeriksaan Payudara
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7) Pemeriksaan Abdomen
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8) Pemeriksaan Genetalia
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9) Pemeriksaan Ekstremitas
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j. Pemeriksaan Neurologis
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k. Pemeriksaan Penunjang
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l. Terapi/Pengobatan/Penatalaksanaan
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Malang,…./
…../2020
Mahasiswa
…………………
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2. Analisa Data

ANALISA DATA

Nama Pasien :
Umur :
No. Register :
B. DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4.
5.
C. PERENCANAAN
1. Prioritas Masalah
DAFTAR MASALAH

Nama Pasien :
Umur :
No. Register :

TANGGAL DIAGNOSA TANGGAL TANDA

No. DX
MUNCUL KEPERAWATAN TERATASI TANGAN
 1. Rencana Asuhan Keperawatan

RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

DIAGNOSA TUJUAN KRITERIA

NO DX INTERVENSI RASIONAL
KEPERAWATAN STANDART
 RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

DIAGNOSA TUJUAN KRITERIA

NO DX INTERVENSI RASIONAL
KEPERAWATAN STANDART
 2. Implementasi
IMPLEMENTASI ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

TANGGAL PUKUL DIAGNOSA KEPERAWATAN IMPLEMENTASI TANDA TANGAN

IMPLEMENTASI ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

TANGGAL PUKUL DIAGNOSA KEPERAWATAN IMPLEMENTASI TANDA TANGAN

 IMPLEMENTASI ASUHAN KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

TANGGAL PUKUL DIAGNOSA KEPERAWATAN IMPLEMENTASI TANDA TANGAN

3. Evaluasi

EVALUASI KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

TANGGAL / PUKUL DIAGNOSA KEPERAWATAN DATA (SOAPIER)