DAFTAR ISI

SK SPO KEPERAWATAN..............................................................................................
i

KATA PENGANTAR........................................................................................................
iii

DAFTAR ISI.....................................................................................................................
v

A. KEPERAWATAN DASAR
1. Batuk Efektif........................................................................................................
1
2. Melakukan Fisioterapi Dada................................................................................
3
3. Pemasangan Oksigen.........................................................................................
6
4. Melepas Selang Penduga Lambung (Naso Gastri Tube)....................................
8
5. Penggantian Cairan Infus....................................................................................
10
6. Melepas Infus......................................................................................................
12
7. Pemasangan NGT (Naso Gastri Tube)...............................................................
14
8. Memberi Makanan Melalui NGT (Naso Gastri Tube)...........................................
16
9. Pemberian Diet...................................................................................................
18
10. Mengukur Tinggi Badan (TB)..............................................................................
19
11. Menimbang Berat Badan Anak dan Bayi ............................................................
20
12. Transfusi Darah...................................................................................................
22
13. Menghitung Tetesan Infus...................................................................................
24
14. Memasang Infus..................................................................................................
26
15. Memberikan Gliserin dengan Spuit ....................................................................
29
16. Memberikan Urinal .............................................................................................
31
17. Memberikan Obat Pencahar Melalui Anal...........................................................
33
18. Bladder Training..................................................................................................
36
19. Pemasangan Kateter Pria dan Wanita ...............................................................
38

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20. Meng-aff Kateter ................................................................................................
41
21. Menolong Pasien Buang Air Besar (BAB) dan Buang Air Kecil (BAK)................
43
22. Mengukur Balance Cairan...................................................................................
45
23. Huknah Rendah..................................................................................................
47
24. Huknah Tinggi.....................................................................................................
49
25. Memberikan Huknah pada Bayi atau Anak.........................................................
51
26. Pemasangan Gelang Identifikasi.........................................................................
53
27. Pelepasan Gelang Identitas................................................................................
55
28. Pencegahan Pasien Jatuh..................................................................................
56
29. Pemasangan Gelang Resiko Jatuh.....................................................................
58
30. Memindahkan Pasien..........................................................................................
59
31. Membantu Pasien Pindah dari Tempat Tidur ke Kursi Roda dan
Sebaliknya..........................................................................................................
61
32. Memandikan Pasien............................................................................................
63
33. Mengganti Pakaian Pasien..................................................................................
67
34. Mengganti Alat Tenun Tempat Tidur Pasien Tanpa Pasein Diatasnya...............
69
35. Memandikan Pasien Dalam Posisi Berbaring......................................................
71
36. Merawat Gigi dan Mulut Pada Pasien Sadar Tetapi Tidak Mampu
Melakukan Sendiri...............................................................................................
74
37. Merawat Rambut.................................................................................................
76
38. Merawat Kuku Pasien.........................................................................................
78
39. Memasang Kap Kutu...........................................................................................
80
40. Manajemen Nyeri dengan Metode Imajinasi Terbimbing.....................................
82
41. Manajemen Nyeri dengan Metode Pemijatan (massage)....................................
84
42. Manajemen Nyeri dengan Metode Relaksasi progresif.......................................
86
43. Manajemen Nyeri dengan Metode Relaksasi......................................................
89

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44. Mengatur Sikap Fowler.......................................................................................
91
45. Mengatur Sikap Dorsal Recumbent.....................................................................
93
46. Mengatur Sikap Sim ...........................................................................................
95
47. Mengatur Sikap Trendelenberg...........................................................................
96
48. Mengatur Sikap Genupectoral (Knee chest)........................................................
98
49. Mengatur Sikap Litotomi......................................................................................
100
50. Mengidentifaksi Respon Nyeri.............................................................................
102
51. Mengidentifaksi Respon Nyeri Pada Pasien Yang Tidak Dapat
Berkomunikasi....................................................................................................
104
52. Mengukur Suhu (ketiak/aksila)............................................................................
108
53. Mengukur Tekanan Darah...................................................................................
110
54. Menghitung Pernafasan......................................................................................
112
55. Menghitung Nadi Perifer......................................................................................
114
56. Kompres Hangat.................................................................................................
116
57. Pemberian Kompres Basah................................................................................
118
58. Pemberian Kompres Kibrat Es............................................................................
120
59. Memberi Kompres Hangat (buli-buli panas)........................................................
122
60. Memberikan Obat Melalui Kulit (topikal)..............................................................
124
61. Memberikan Obat Melalui Pernafasan................................................................
127
62. Memberikan Obat Melalui Hidung.......................................................................
129
63. Membilas (Irigasi) Mata.......................................................................................
131
64. Memberikan obat Tetes Telinga..........................................................................
133
65. Membilas (irigasi) telinga.....................................................................................
135
66. Pemberian Obat Melalui Intracutan.....................................................................
138
67. Pemberian Obat Melalui Intramuscular...............................................................
140
68. Pemberian Obat Melalui Intravena......................................................................
142

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69. Pemberian Obat Melalui Oral..............................................................................
144
70. Pemberian Obat Melalui Subcutan......................................................................
146
71. Pemberian Obat Melalui Vagina..........................................................................
148
72. Pemberian Sulfas Magnesikus............................................................................
150
73. Memasukan Obat Melalui Anus..........................................................................
152
74. Vulva hygiene.....................................................................................................
154
75. Pengambilan Specimen Feses pada Pasien Minimal Care.................................
156
76. Pengambilan Specimen Feses pada Pasien Bed rest/tidak sadar......................
158
77. Pengambilan Specimen Urine pada Pasien Minimal Care..................................
160
78. Pengambilan Specimen Urine pada Pasien Bedrest/ tidak sadar/
Terpasang Kateter..............................................................................................
162
79. Pengambilan Spesimen Darah............................................................................
164
80. Membantu Pasien Melaksanakan Ibadah Sholat................................................
166
81. Memberikan Pelayanan Mental Spiritual kepada Pasien Gawat Terminal...........
168
82. Pelayanan Mental Spiritual kepada Pasien yang Menghadapi Sakaratul
Maut....................................................................................................................
170
83. Perawatan Pasien yang Meninggal.....................................................................
171
84. Mencabut Bulu Mata...........................................................................................
173
85. Memberi Obat Mata............................................................................................
175
86. Perawatan Pasien Pra Pembedahan Elektif .......................................................
177
87. Perawatan Pasien Pasca Pembedahan..............................................................
179
88. Cuci Tangan dengan Air......................................................................................
181
89. Cuci Tangan dengan Antiseptik Berbasis Alkohol...............................................
183
90. Memakai Sarung Tangan Steril...........................................................................
184
91. Memakai Skort Kerja...........................................................................................
185
92. Pengoperasian Sterilisator..................................................................................
186

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 93. Memasang Renstrain..........................................................................................
188
94. Penyimpanan Obat High Allert............................................................................
190
95. Mengantar Pasien yang akan Menjalani Fisioterapi............................................
192
96. Mobilisasi Pasien yang akan Menjalani Pemeriksaan Penunjang
(EKG,USG,PA,EGG)...........................................................................................
194
97. Mengantar pasien yang akan menjalani pemeriksaan foto thorax.......................
196
98. Menyiapkan pasien yang akan pulang dengan keadaan sehat...........................
198
99. Evakuasi Gempa bumi........................................................................................
200
100. Evakuasi Gunung Merapi Meletus...................................................................
202
101. Evakuasi Kebakaran........................................................................................
204
102. Evakuasi Penanggulangan banjir.....................................................................
206
103. Evakuasi Tanah longsor...................................................................................
208
104. Menyiapkan klien yang akan pulang atas permintaan sendiri..........................
210
105. Menerima Pasien Baru.....................................................................................
211
106. Nebulizer..........................................................................................................
213

B. BEDAH (BD)
BD-1 Perawatan Luka Bakar.....................................................................................
215
BD-2 Memandikan Pasien Luka Bakar.....................................................................
218
BD-3 Pengkajian Luka..............................................................................................
220
BD-4 Perawatan Luka Akut.......................................................................................
222
BD-5 Perawatan Luka Gangren................................................................................
224
BD-6 Perawatan Luka Dekubitus (Luka Tirah Baring Lama).....................................
227
BD-7 Nekrotomi........................................................................................................
230
BD-8 Angkat Jahitan.................................................................................................
232
BD-9 Perawatan Pasca Trakeostomi........................................................................
234
BD-10 Angkat Drain..................................................................................................
236

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 BD-11 Pengkajian Stoma..........................................................................................
238
BD-12 Irigasi Stoma..................................................................................................
240
BD-13 Pemasangan Kantong Stoma........................................................................
243
BD-14 Pemasangan Beban Traksi............................................................................
246
BD-15 Perawatan Traksi...........................................................................................
248
BD-16 Perawatan Kolostomi.....................................................................................
250
BD-17 Mengganti Verban..........................................................................................
252
BD-18 Abses.............................................................................................................
254
BD-19 Edukasi Pasien Diabetes Melitus...................................................................
256
BD-22 Mengganti Balutan Kering Luka Jahit Pasca Operasi....................................
258
BD-23 Melepas Douwer Kateter...............................................................................
261
BD-24 Melepas Drainage thorax...............................................................................
263
BD-25 Memasang Gips.............................................................................................
265
BD-26 Kelainan Refraksi...........................................................................................
267
BD-27 Memasang Bidai............................................................................................
269

C. MATERNITAS (MT)
MT-1 Asuhan Persalinan Normal..............................................................................
271
MT-2 Asuhan Persalinan Normal Kala I....................................................................
273
MT-3 Asuhan Persalinan Normal Kala II...................................................................
275
MT-4 Manajemen Aktif Kala III..................................................................................
278
MT-5 Pemantauan Kala IV........................................................................................
280
MT-6 Pemeriksaan Leopold......................................................................................
282
MT-7 Pemeriksaan Denyut Jantung Janin................................................................
285
MT-8 Pemeriksaan Dalam (Vaginal Toucher)...........................................................
286
MT-9 Pemasangan AKDR Pasca Plasenta...............................................................
288

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 MT-10 Serah Terima Bayi Pulang.............................................................................
291
MT-11 Pemasangan AKDR.......................................................................................
293
MT-12 Pencabutan AKDR.........................................................................................
295
MT-13 Pemasangan Implant.....................................................................................
297
MT-14 Pencabutan Implant.......................................................................................
299
MT-15 Penanganan Molahidatidosa.........................................................................
301
MT-16 Episotomi.......................................................................................................
303
MT-17 Inisiasi Menyusui Dini (IMD)..........................................................................
305
MT-18 Kompresi Aorta Abdominalis..........................................................................
307
MT-19 Payudara Postnatal.......................................................................................
309
MT-20 Pemeriksaan Fisik BAyi Baru Lahir................................................................
311
MT-21 Persiapan Pasien Sectio Caesarea (SC).......................................................
314
MT-22Penjahitan Robekan Portio.............................................................................
317
MT-23 Rawat Gabung Ibu dan Bayi (Roming –In)....................................................
319
MT-24 Tindakan Klinik Ruptur Perineum dan Vagina................................................
321
MT-25 Persiapan dan Perawatan Pasien Curretage.................................................
323
MT-26 Perawatan Perineum.....................................................................................
327
MT-27Penanganan Kehamilan Ektopik Terganggu...................................................
330
MT-28 Penanganan Preeklampsi..............................................................................
333

D. ANAK (AN)
AN-1 PengoperasianInkubator..................................................................................
336
AN-2 Tindakan Photo Therapy..................................................................................
338
AN-3 Pemberian Dysperal........................................................................................
340
AN-4 Pemasangan Infus Wing Needle......................................................................
342
AN-5 USG Abdomen pada Anak...............................................................................
345

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 AN-6 Mengganti Pakaian Bayi..................................................................................
347
AN-7 Memberi Minum Bayi.......................................................................................
349

E. KRITIS (KR)
KR-1 Penatalaksanaan Treadmill..............................................................................
351
KR-2 Cara Menggunakan Bed Side Monitor.............................................................
353
KR-3 Cara Menggunakan Syringe Pump..................................................................
355
KR-4 Cara Menggunakan Infusion Pump..................................................................
357
KR-5 Melakukan Pemasangan Oxymetri..................................................................
359
KR-6 Monitoring Ventilator........................................................................................
360
KR-7 Tindakan Ekstubasi..........................................................................................
362
KR-8 Prosedur Pasien Masuk Kekamar Operasi......................................................
364
KR-9 Prosedur Pasien Keluar dari kamar Operasi....................................................
366
KR-10 Penerimaan Pasien Sebelum Operasi Di Ruang Persiapan..........................
368
KR-11 Prosedur Keamanan Pembedahan (sign In)..................................................
370
KR-12 Prosedur Keamanan Pembedahan (Sign Out)...............................................
372
KR-13 Sistem Operan Shift Jaga Perawat IGD.........................................................
373
KR-14 Pasien Masuk ke Instalasi Gawat Darurat.....................................................
375
KR-15 Pelayanan Pasien Gawat Darurat (P1)..........................................................
377
KR-16 Penanganan Pasien Gawat Tidak Darurat dan Darurat Tidak Gawat
(P2)................................................................................................................
379
KR-17 Penanganan Pasien Tidak Gawat Tidak Darurat (P3)...................................
382
KR-18 Penanganan Pasien Dengan Death of Arrival (P4)........................................
384
KR-19 Pemberian Terapi Inhalasi ............................................................................
386
KR-20 Penanganan Pasien Meninggal Di Instalasi Gawat Darurat ..........................
388
KR-21 Pasien Pulang dari IGD.................................................................................
390
KR-22 Resusitasi......................................................................................................
391

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 KR-23 Melakukan Suction.........................................................................................
393
KR-24 Pemeriksaan Spirometri.................................................................................
395
KR-25 Pemeriksaan USG.........................................................................................
398
KR-26 Penggunaan Elektro Surgical.........................................................................
401
KR-27 Penggunaan Hawlet Packed Monitor.............................................................
403
KR-28 Penggunaan Insuflator CO2...........................................................................
406
KR-29 Tehnik Penggunaan DC Shock......................................................................
408
KR-30 Identifikasi Pasien dan Penanggulangannya.................................................
410
KR-31 Syok Hipovolemik..........................................................................................
412
KR-32 Syok Anafilaktik.............................................................................................
414
KR-33 Unit Indikasi Masuk Dan Keluar Perawatan Intensif.......................................
416
KR-34 Menyiapkan pasien yang akan pulang dengan keadaan kritis atau
dirujuk............................................................................................................
418

F. MANAJEMEN (MJ)
MJ-1 Penerimaan Pasien Rawat Inap.......................................................................
421
MJ-2 Pasien/Keluar Pulang dari Ruang Rawat Inap.................................................
424
MJ-3 Transfer Pasien Antar Ruang Rawat Inap........................................................
427
MJ-4 Komunikasi Perawat dengan Menggunakan SBAR.........................................
429
MJ-5 Manajemen Ansietas........................................................................................
431
MJ-6 Orientasi Petugas Baru....................................................................................
433
MJ-7 Orientasi Staf...................................................................................................
435
MJ-8 Uraian Tugas Kepala Ruangan Rawat Inap.....................................................
436
MJ-9 Uraian Tugas PJ Tim/Katim.............................................................................
439
MJ-10 Uraian Tugas Dokter Pelaksana....................................................................
443
MJ-11 Uraian Tugas Perawat Pelaksana..................................................................
445
MJ-12 Pelayanan Rawat Inap...................................................................................
448

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 MJ-14 Penolakan Resusitasi (DNR)..........................................................................
450
MJ-15 Skrining Pasien..............................................................................................
452
MJ-16 Pasca Skrining Pasien...................................................................................
454
MJ-17 Informed Consent...........................................................................................
456
MJ-18 Komunikasi Efektif Melalui Telepon................................................................
458
MJ-19 Pengurusan Surat Elegibilitas Peserta (SEP).................................................
460
MJ-20 Operan Pasien...............................................................................................
462
MJ-21 Transfer Pasien Didalam Rumah Sakit..........................................................
463
MJ-22 Tempat Tidur Terbatas...................................................................................
465
MJ-22 Melakukan Rujukan dan Pindah Rawat Pasien ke Rumah Sakit lain.............
466............................................................................................................................
MJ-23 Pemilahan Sampah di Ruangan.....................................................................
468

DAFTAR PUSTAKA

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