SEKOLAH TINGGI ILMU KESEHATAN

“HUTAMA ABDI HUSADA”

Ijin Pendirian Mendiknas RI Nomor : 113/D/O/2009

Jl. Dr. Wahidin Sudiro Husodo Telp./Fax: 0355-322738

Tulungagung 66224
Alamat E-mail : stikeshahta@yahoo.co.id

FORMAT PENGKAJIAN
DI KAMAR OPERASI
NO. MR :

Diagnosa medis : ………..............…………… Dikirim tanggal : …..........……………….

Tanggal pengkajian : ………...………………….. Dikirim ruangan : ………..........………….
Jam : …………...………………. Jenis Operasi : …………………………

PRE OPERASI

A. IDENTITAS KLIEN
Nama : ………………………………………...
Umur : …………………………………………
Jenis kelamin : …………………………………………
Suku / bangsa : …………………………………………
Agama : …………………………………………
Pendidikan : ………………………………………….
Pekerjaan : ………………………………………….
Alamat : …………………………………………..
Biaya oleh : BPJS / Sendiri / Lain-lain ...................

B. RIWAYAT KEPERAWATAN (NURSING HISTORY)

Keluhan Utama :
1. Di rumah:
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2. Saat
pengkajian: ..............................................................................................................................
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3. Riwayat Penyakit (PORST):
Di rumah:
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Saat
pengkajian: ..............................................................................................................................
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4. Upaya Yang Telah Dilakukan :
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5. Operasi Yang Pernah Dilakukan :
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C. PEMERIKSAAN FISIK
1. Keadaan umum
2. Tanda – tanda vital
Suhu : ………….. C
Nadi : ………....... X / Mnt
Respirasi : ………….. X / Mnt
Tekanan Darah : .................. mmHg
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 Catatan
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3. Body system (review of system
a. Pernafasan (B1 / Breathing)
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b. Cardiovaskuler (B2 / Bleeding)
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c. Persyarafan (B3 / Brain)
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d. Perkemihan – Eliminasi uri (B4 / Bladder)

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e. Pencernaan – Eliminasi alvi (B5 / Bowel)
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f. Tulang – otot – integument (B6 / Bone)
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g. Sistem indokrin
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h. Reproduksi
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i. Psikososial
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j. Spiritual
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D. PEMERIKASAAN PENUNJANG
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E. ANALISA DATA PRE OPERASI

S E P

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F. DIAGNOSA KEPERAWATAN
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G. INTERVENSI
1. Tujuan :
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2. Kriteria Hasil :
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3. Intervensi:
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H. IMPLEMENTASI
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I. EVALUASI
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INTRA OPERASI

1. Operasi jam : ……………………. WIB s/d jam …………………… WIB

Operator : …………………………………………………………
Keadaan umum .........
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3. Tanda – tanda vital
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 Suhu : ………….. C
Nadi : ………....... X / Mnt
Respirasi : ………….. X / Mnt
Tekanan Darah : .................. mmHg
4. Catatan operasi
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5. Instrumen
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POST OPERASI
4 | STIKES HAH 2016
 1. Operasi jam : ……………………. WIB s/d jam …………………… WIB
2. Keadaan Umum :
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3. Tanda – tanda vital
S : ……………. C N : ………….. x/mnt
R : ……………. x/mnt Tek. Darah : …………….mmHg
4. Catatan
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A. ANALISA DATA POST OPERASI

S E P

B. DIAGNOSA KEPERAWATAN
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C. INTERVENSI
Tujuan
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Kriteria Hasil

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 ………………………………………………………………………………………………….
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Intervensi
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D. IMPLEMENTASI
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E. EVALUASI
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Tanggal : ........................ Tanda Tangan

Nama Perawat : ........................

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