ASUHAN KEPERAWATAN ........................

DENGAN DIAGNOSA MEDIS .........................................

DI RUANG INSTALASI BEDAH SENTRAL (IBS)................................

Disusun Oleh :

PROGRAM STUDI KEPERAWATAN (S1) & NERS

SEKOLAH TINGGI ILMU KESEHATAN WIRA HUSADA
YOGYAKARTA
2020
 HALAMAN PENGESAHAN

Resume Asuhan Keperawatan Perioperatif

Pada.........dengan Diagnosa Medis ....................
Di Ruang Instalasi Bedah Sentral (IBS)............................

Resume Asuhan Keperawatan ini telah dibaca dan diperiksa pada

Hari/tanggal: .................................................

Pembimbing Klinik Mahasiswa

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

Mengetahui,
Pembimbing Akademik

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 RESUME ASUHAN KEPERAWATAN PERIOPERATIF PADA .........
DENGAN DIAGNOSA MEDIS .............................................
DI RUANG INSTALASI BEDAH SENTRAL (IBS) .....................................

Hari/Tgl Pengkajian : Jam : WIB

Nama Mahasiswa :
NIM :
Rumah Sakit / Ruang :
Sumber Data :
Metode Pengumpulan Data : Wawancara, Observasi, Pemeriksaan Fisik, Studi Dokumentasi

I. IDENTITAS KLIEN
Nama : ........................................................................................................
Tempat Tanggal Lahir : ........................................................................................................
Umur : ........................................................................................................
Jenis Kelamin : ........................................................................................................
Agama : ........................................................................................................
Pekerjaan : ........................................................................................................
Alamat : ........................................................................................................
No. RM : ........................................................................................................
Tanggal Operasi : ........................................................................................................
Diagnosa Medis : ........................................................................................................
Nama Tindakan : ........................................................................................................
Jenis Anestesi : ........................................................................................................
Nama Penanggung Jawab : ........................................................................................................
Hubungan dengan Pasien : ........................................................................................................

II. RIWAYAT PENYAKIT SEKARANG

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III. RIWAYAT PENYAKIT DAHULU

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IV. RIWAYAT PENYAKIT KELUARGA

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V. DATA PENUNJANG
A. Laboratorium

Hari/
tanggal/ Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
jam

B. Radiologi dll
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VI. FASE PRE OPERASI
a. Pengkajian Kesehatan
1) Jenis operasi : .................................................................................
2) Jenis anestesi : .................................................................................
3) Alergi obat : .................................................................................
4) Riwayat merokok : .................................................................................
5) Riwayat mengonsumsi alkohol : .................................................................................
6) Riwayat penyakit kronik : .................................................................................

b. Keadaan Umum Pasien

1) Kondisi umum : .................................................................................
2) Tekanan darah : .................................................................................
3) Nadi : .................................................................................
4) Respirasi : .................................................................................
5) Suhu : .................................................................................
6) SpO2 : .................................................................................

c. Status Emosional
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d. Persiapan Operasi
Observasi
No Item Observasi
Ya Tidak
1 Pencukuran area yang akan dioperasi
2 Baju operasi
3 Cat kuku
4 Make up
5 Informed consent
6 Aksesoris jam, gelang, jepit rambut, cincin
7 Gigi palsu
8 Pemeriksaan penunjang
9 Darah
10 Urine
11 Radiologi
12 USG
13 Personal hygiene
14 Pemasangan kateter
15 Premedikasi pre-operatif
e. Terapi Medis Pre Operatif
N
Nama Obat Dosis Fungsi Rute
o

f. Analisa Data Pre Operatif

No Data Fokus Masalah Penyebab

g. Diagnosa Keperawatan
1) ...................................................................................................................................
2) ...................................................................................................................................
3) ...................................................................................................................................
 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil Intervensi
 CATATAN PERKEMBANGAN PERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

No Paraf
Hari,Tanggal Implementasi Evaluasi (SOAP) dilakukan diakhir shift jaga
Dx Nama
VII. FASE INTRA OPERASI
1. Persiapan

N Observasi
Item Observasi
o Ya Tidak
1 Mencuci Tangan Steril
2 Mengeringkan tangan dengan lap/handuk tangan steril
3 Memakai baju operasi steril
4 Memakai handscone steril
5 Cek nama pasien
6 Cek tindakan operasi

2. Prosedur Anestesi
a. Jenis anestesi : ................................................................................................
b. Teknik : ................................................................................................
c. Obat
1) ............................................................................................................................
2) ............................................................................................................................
3) ............................................................................................................................
4) ............................................................................................................................
5) ............................................................................................................................
d. Posisi anestesi : ................................................................................................
3. Persiapan Alat dan Ruang
Alat Tidak Steril :
a. Hypafix
b. Gunting verban / Bandage scissors
c. Ground beserta alat mesinnya
d. Lampu operasi
e. Meja operasi
f. Meja instrumen
g. Standar infus
h. Monitor
i. Mesin suction
j. Tempat sampah
Alat Steril :
a. Kassa : ......... buah
b. Pinset cirugis : ......... buah
c. Pincet anatomi : ......... buah
d. Gunting : ......... buah
e. Towel klem : ......... buah
f. Scapel mess : ......... buah
g. Allis klem : ......... buah
h. Atraumatic needle : ......... buah
i. Kom : ......... buah
j. Bengkok : ......... buah
k. Arteri klem : ......... buah
l. Needle order : ......... buah
 m. Duk besar : ......... buah
n. Duk kecil : ......... buah
o. Duk lubang I : ......... buah
p. Duk klem : ......... buah
q. Klem desinfektan : ......... buah
r. Alcohol 70% : ......... buah
s. Pavidone iodine : ......... buah
t. Nail holder : ......... buah
u. Bisturi : ......... buah
v. Pean : ......... buah
w. Koker : ......... buah
x. Couter : ......... buah
y. O hak : ......... buah
z. L hak : ......... buah
Jika ada instrument lain silahkan ditambahkan
aa. Gunting jaringan : ......... buah
bb. Benang silk 2-0 dan jarum taper ½ circle
cc. Benang PGA 3-0 dan jarum cutting ½ circle
dd. Gunting benang : ......... buah
ee. Benang PGA 2-0 dan jarum taper ½ circle
ff. Benang silk 3-0 dan jarum taper ½ circle
Bahan Medis Habis Pakai :
a. Sarung tangan bermacam-macam ukuran
b. Desinfektan: betadine dan alcohol 70%, NaCl 0,9%
c. Kassa
d. Spuit 10 cc : ......... buah

4. Prosedur operasi:
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5. Kaji data-data berikut selama prosedur operasi
a) IV line (jenis cairan, banyak cairan masuk)
Jenis cairan : ...........................................................................................
Banyak cairan : ...........................................................................................
Posisi pembedahan :
 Supine  Tengkurap  Miring kanan
 Agak miring kiri  Litotomi  Lain-lain
b) Restrain pengaman pasien
Restrain : ...........................................................................................
c) Persiapan area operasi
Area yang dibersihkan : ...........................................................................................
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...................................................................................................................................
Jenis cairan yang digunakan : ...............................................................................
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d) Monitoring tanda-tanda vital
Masalah
Waktu
TD Nadi Pernapasan terkait Intervensi
(30 menit)
sirkulasi

e) Temuan data yang lain selama prosedur operasi : ................................................

f) Lama operasi : ...........................................................................................

h. Analisa Data Intra Operatif

No Data Fokus Masalah Penyebab

No Data Fokus Masalah Penyebab

i. Diagnosa Keperawatan
1) ...................................................................................................................................
2) ...................................................................................................................................
3) ...................................................................................................................................
 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil (NOC) Intervensi Keperawatan (NIC)
 CATATAN PERKEMBANGAN PERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

No Paraf
Hari,Tanggal Implementasi Evaluasi (SOAP) dilakukan diakhir shift jaga
Dx Nama
VIII. FASE POST OPERATIF
a) Tanda-tanda vital
Intervensi
Waktu BP HR RR SpO2 Masalah
(jika ada)

b) Kondisi umum pasien

Hasil observasi Kapan reflek kembali

Reflek muntah

Reflek batuk

Kesadaran

c) Balance cairan
Total intake Total output

Jenis : Jumlah : Jenis : darah, urine, IWL Jumlah :

Cairan infus : Drain :

Transfusi : Urine :

Perdarahan :

IWL :

Total : Total :

Balance cairan : input - output

Balance cairan : ........................................................................................................
BC : ........................................................................................................
d) Aldretee Score
No Kriteria Score Nilai

1. Warna Kulit

Kemerahan/normal 2

Pucat 1

Sianosis 0

2. Aktifitas Motorik

Gerak 4 anggota tubuh 2

Gerak 2 anggota tubuh 1

Tidak ada gerakan 0

3. Pernapasan

Napas dalam, batuk dan tangis kuat 2

Napas dangkal dan adekuat 1

 No Kriteria Score Nilai

Apnea atau napas tidak adekuat 0

4. Sirkulasi

± 20 mmHg dari pre operasi 2

20-50 mmHg dari pre operasi 1

> 50 mmHg dari pre operasi 0

5. Kesadaran

Sadar penuh, mudah dipanggil 2

Bangun jika dipanggil 1

Tidak ada respon 0

Nilai Aldrete : ........................................................................................................

Keterangan :
1) Pasien dapat dipindah ke bangsal jika score minimal 8
2) Pasien dipindah ke ICU jika score <8 dan telah dirawat selama 2 jam

e) Status keamanan dan kenyamanan pasien

 Nyeri (O, P, Q, R, S, T, U, V)
Onset : ........................................................................................................
Provocation : ........................................................................................................
Quality : ........................................................................................................
Regio : ........................................................................................................
Radiation : ........................................................................................................
Severity : ........................................................................................................
Treatment : ........................................................................................................
Impact to U : ........................................................................................................
Value : ........................................................................................................
 Side rail : ........................................................................................................
 Restrain : ........................................................................................................

f) Terapi Medis Post Operatif

N
Nama Obat Dosis Fungsi Rute
o
g) Analisa Data Post Operatif

No Data Fokus Masalah Penyebab

h) Diagnosa Keperawatan
1) ...................................................................................................................................
2) ...................................................................................................................................
3) ...................................................................................................................................
 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil (NOC) Intervensi (NIC)
 CATATAN PERKEMBANGAN PERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

No Paraf
Hari,Tanggal Implementasi Evaluasi (SOAP) dilakukan diakhir shift jaga
Dx Nama