KEPERAWATAN
PROGRAM PROFESI NERS
KEPERAWATAN
PERIOPERATIF
LOGBOOK
(LEMBAR KERJA MAHASISWA)
KES
Logbook_presepte _Perioperatif _Poltekkes Tanjungkarang| i
ANG
A III
ANG
POLITEKNIK KESEHATAN TANJUNGKARANG
PROGRAM STUDI PENDIDIKAN PREFESI NEERS
PROGARM PROFESI
VISI DAN MISI
Foto
NIM : ...................................
1. Setiap mahasiswa wajib membuat dan mengisi daftar hadir praktik klinik
2. Membuat laporan pendahuluan asuhan keperawatan pada pasien yang
akan dilakukan operasi setiap minggu satu laporan
3. Mahasiswa setiap hari wajib membuat analisis tindakan pada kasus yang
diikuti tindakan operasinya secara penuh satu laporan
4. Membuat Activity Daily Living setiap hari, dan disyahkan oleh pembimbing
lahan atau yang mendampingi.
5. Mahasiswa membuat laporan asuhan keperawatan pre, intra dan post
operasi di kamar operasi pada semua sistem, setiap minggu satu kasus
yang berbeda.
6. Setiap mahasiswa wajib memenuhi target keterampilan yang telah
ditetapkan pihak akademik minimal 80% dari seluruh keterampilan yang
harus dicapai.
7. Setiap kelompok wajib mempresentasikan hasil asuhan keperawatan
yang telah dilakukan setelah akhir masa dinas.
*) Bagi mahasiswa yang target kompetensinya < 80%, akan diberi sanksi
1. Di Dinaskan kembali untuk mencapai targetn kompetensi
2. Bila sudah didinaskan kembali belum juga terpenuhi, maka akan
mencapai komptensi di Laboratorium
2. Afektif : 30%
a. Disiplin
b. Penerapan etika profesi
c. Kerjasama teamwork
3. Psikomotor : 40%
a. Target kompetensi
b. Supervisi tindakan
c. Laporan asuhan keperawatan
d. Rencana dan Pelaksanaan Penkes
Rentang Nilai
Mutu Rentang Kelulusan
A 79 - 100 Lulus
B 68 - 78 Lulus
C 56 - 67 Lulus
D 41 – 55 Lulus
E 0 - 40 Lulus
Yang dimaksud dengan nilai LULUS adalah minimal nilai mutu B (Nilai 68 –
78).
Nilai akhir menjadi hak prerogatif pembimbing/preceptor dan bagian yang
bersangkutan
Pre / Post
Conference
Ruangan :
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Waktu Kegiatan
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Pre / Post
Conference
Ruangan :
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Waktu Kegiatan
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Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
Pre / Post
Conference
Ruangan :
----------------------
Waktu Kegiatan
…………………………
A. Dasar Teori
1. Definisi Diagnosa Medis
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2. Epidemiologi Kasus
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3. Etiologi
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6. Penatalaksanaan Medis
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7. Patofisiologi / Pathway
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B. ASUHAN KEPERAWATAN
1. Daftar Diagnosis Keperawatan yang mungkin muncul Pada Kasus
Pre, Intra Dan Post Operatif (Minimal 3 Diagnosis Keperawatan) &
Definisi Masalah Keperawatan Secara Teoritis (Lihat Buku Saku
Diagnosa Sdki/Nanda)
1) Diagnosis Keperawatan :
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Definisi :
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DS & DO Yg mendukung
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Tujuan :
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Rencana Intervensi :
1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4_. _______________________________________________________________________________
5._________________________________________________________________________________
6._________________________________________________________________________________
7._________________________________________________________________________________
8.________________________________________________________________________________
2) Diagnosis Keperawatan :
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Definisi :
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Tujuan :
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Rencana Intervensi :
1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4_.
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5._________________________________________________________________________________
6._________________________________________________________________________________
7._________________________________________________________________________________
8._________________________________________________________________________________
3) Diagnosis Keperawatan :
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Definisi :
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DS & DO Yg mendukung
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Tujuan :
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Rencana Intervensi :
1._________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4_. _______________________________________________________________________________
5._________________________________________________________________________________
6._________________________________________________________________________________
7._________________________________________________________________________________
8._________________________________________________________________________________
DAFTAR PUSTAKA
1. __________________________________________________________________
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2. __________________________________________________________________
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3. __________________________________________________________________
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4. __________________________________________________________________
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5. __________________________________________________________________
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6. __________________________________________________________________
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7. __________________________________________________________________
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8. __________________________________________________________________
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9. __________________________________________________________________
10. __________________________________________________________________
Bandarlampung, ……………….
Pembimbing Klinik (Akademik) Clinical Instructure (CI)
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I. PENGKAJIAN
Identitas Klien
Nama : No. RM :
Umur : Tgl. MRS :
Jenis Kelamin : Diagnosa :
Suku/Bangsa :
Agama :
Pekerjaan :
Pendidikan :
Gol. Darah :
Alamat :
Tanggungan :
A. Riwayat Praoperatif
1. Pasien mulai dirawat tgl : pkl : .................
Ruang : ………………………..
2. Ringkasan hasil anamnese preoperatif :
.........................................................................................................................................
........................................................................................................................................
.
........................................................................................................................................
.
........................................................................................................................................
.
........................................................................................................................................
3. Hasil pemeriksaan fisik
a. Tanda- tanda vital, Tgl : …..............................Jam :......................................
Kesadaran : ...................... GCS : .................... Orientasi : ...........................
Suhu : ……………… Tensi : ……………… Nadi : ………………. RR : ………………
b. Pemeriksaan Fisik
Kepala &
Leher : ...................................................................................................
...........
..............................................................................................................
..............................................................................................................
Thorax (jantung &
paru) : ...................................................................................................
...........
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3. Pemeriksaan Penunjang :
a. ECG Tgl: .........................................Jam :............................................
Hasil :...............................................................................................................
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b. X- Ray Tgl :…………….. .................... Jam : ……………...................................
Hasil :..............................................................................................................
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c. Hasil laboratorium, Tgl :....................................... Jam : ...............................
Hasil :...............................................................................................................
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d. Pemeriksaan lain:
Hasil :……………………………………………………………………………….................
……………………………………………………………………………………….......
5. Pemberian obat-obatan :
a. Obat Premedikasi (diberikan sebelum hari pembedahan)
Tgl / jam Nama Obat Jenis Obat Dosis Rute
B. INTRAOPERATIF
C. POST OPERASI
1. Pasien pindah ke :
Pindah ke PACU/ICU/PICU/NICU, jam___________Wi
2. Keluhan saat di RR/PACU : ...........................................................
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3. Air
Way : ..................................................................................................
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...........
4. Breathing : ..........................................................................................
.......................... .................................................................................
..................
5. Sirkulasi : ...........................................................................................
........................... ................................................................................
.................
Logbook_presepte _Perioperatif _Poltekkes Tanjungkarang| 21
6. Observasi Recovery Room
KETERANGAN
Pasien dapat dipindah kebangsal, jika score minimal 8
Pasien dipindahke ICU, jika score < 8 setelah dirawat selama 2 jam
BROMAGE SCORE
NO KRITERIA SCORE SCORE
1 Dapat mengangkat tungkai bawah 0
Tidak dapat menekuk lutut tetapi dapat
2 1
mengangkat kaki
Tidak dapat mengangkat tungkai bawah
3 2
tetapi masih dapat mengangkat lutut
Tidak dapat mengangkat kaki sama
4 3
sekali
KETERANGAN
Pasien dapat di pindah kebangsal, jika score kurang dari 2
KETERANGAN
Score ≥ 5 boleh keluar dari RR
10.Balance cairan
Pukul Intake Jml (cc) Output Jml (cc)
Oral Urine
Enteral Muntah
Parenteral IWL
… …
Jumlah Jumlah
Pengobatan
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Leher
Dada
Abdomen
Genitalia
Logbook_presepte _Perioperatif _Poltekkes Tanjungkarang| 23
Integumen
Ekstremitas
I. ANALISA DATA
Masalah
Data Subyektif & Obyektif Etiologi
Keperawatan
Pre Operasi
Intra Operasi
Intra Operasi
Post Operasi
Prosedur
tindakan
Tanggal : ......................................................................................................................
Nama Mahasiswa : ......................................................................................................................
Tempat Praktik : ......................................................................................................................
Waktu Kegiatan
Preseptor klinik,
(________________)
HALAMAN JUDUL
KATA PENGANTAR
DAFTAR ISI
BAB I PENDAHULUAN
1. Latar Belakang
2. Tujuan
3. Manfaat
4. Pengkajian kebutuhan belajar pada sasaran
DAFTAR PUSTAKA
HALAMAN JUDUL
KATA PENGANTAR
DAFTAR ISI
BAB I. PENDAHULUAN (Pindahkan isi LP ke dalam bagian ini dengan format
sub bab)
1.1. Dasar Teori
DAFTAR PUSTAKA
LAMPIRAN
Berisi fotocopy laporan asuhan keperawatan asli yang diseminarkan
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