FORMAT RESUME KASUS

DI KAMAR OPERASI

1. Identitas Klien
Nama :
Jenis Kelamin :
Umur :
Status :
Agama :
Tanggal masuk :
Tanggal pengkajian :
Riwayat Kesehatan
Dx Medis :
Rencana Operasi :

2. Proses Keperawatan
a. Pre Operasi (Ruang Persiapan Operasi)
1) Data Fokus
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2) Diagnosa Keperawatan/Masalah Kolaborasi
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3) Evaluasi
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b. Intra Operasi (Ruang Operasi)

1) Laporan Intra Operasi
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2) Diagnosa Keperawatan/Masalah Kolaborasi
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3) Intervensi/Implementasi
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4) Evaluasi
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c. Post Operasi (Recovery Room)
1) Data Fokus
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2) Diagnosa Keperawatan/Masalah Kolaborasi
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3) Intervensi/Implementasi
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4) Evaluasi
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