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 dari ruangan : .....................................
Jam : ..................................................... Jenis Operasi : .....................................

PRE OPERASI
A. IDENTITAS KLIEN
Nama (Inisial) : ......................................................................................................................................
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
...............................................................................................................................................................
2. Saat pengkajian
...............................................................................................................................................................
...............................................................................................................................................................
3. Riwayat Penyakit (PORST)
a. Di rumah
..........................................................................................................................................................
..........................................................................................................................................................
b. Saat pengkajian
..........................................................................................................................................................
..........................................................................................................................................................
4. Upaya Yang Telah Dilakukan
...............................................................................................................................................................
...............................................................................................................................................................
5. Operasi Yang Pernah Dilakukan
...............................................................................................................................................................
...............................................................................................................................................................

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

C. PEMERIKSAAN FISIK
1. Keadaan umum
2. Tanda – tanda vital
Suhu : .......................................... oC
Nadi : .......................................... x/menit
Respirasi : .......................................... x/menit
Tekanan Darah : .......................................... mmHg
Catatan :
...............................................................................................................................................................
...............................................................................................................................................................

3. Body system (review of system

a. Pernafasan (B1 / Breathing)
..........................................................................................................................................................
..........................................................................................................................................................
b. Cardiovaskuler (B2 / Bleeding)
..........................................................................................................................................................
..........................................................................................................................................................
c. Persyarafan (B3 / Brain)
..........................................................................................................................................................
..........................................................................................................................................................

d. Perkemihan – Eliminasi urin (B4 / Bladder)

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

e. Pencernaan – Eliminasi alvi (B5 / Bowel)

..........................................................................................................................................................
..........................................................................................................................................................
f. Tulang – otot – integument (B6 / Bone)
..........................................................................................................................................................
..........................................................................................................................................................
g. Sistem indokrin
..........................................................................................................................................................
..........................................................................................................................................................
h. Reproduksi
..........................................................................................................................................................
..........................................................................................................................................................
i. Psikososial
..........................................................................................................................................................
..........................................................................................................................................................
j. Spiritual
..........................................................................................................................................................
..........................................................................................................................................................

D. PEMERIKSAAN PENUNJANG
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................

E. TERAPI PRE MEDIKASI

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

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 DIAGNOSA KEPERAWATAN
(*AKTUAL / RESIKO / PROMKES)

Nama/Inisial : .........................................................................................................................................
Umur : .........................................................................................................................................
No. Register : .........................................................................................................................................

Komponen Diagnosa Tanda dan Gejala

Mayor
Subjektif Objektif

Dibuktikan dengan Minor

Subjektif Objektif

Faktor Resiko (Untuk Dx Resiko)

Tanggal muncul Dx
Masalah (Problem)
Kode Masalah D.
Berhubungan dengan
(Penyebab)

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 LUARAN (*UTAMA / TAMBAHAN)
Komponen Luaran Keterangan

Diagnosa Keperawatan
Label
Kode Label L.
Ekspektasi *Meningkat / Menurun / Membaik
Target
Kriteria Hasil

INTERVENSI KEPERAWATAN
Komponen Intervensi Keterangan
Label
Kode Label I.

Observasi, Terapeutik, Edukasi dan Kolaborasi

Intervensi

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 IMPLEMENTASI KEPERAWATAN
Komponen
Keterangan
Intervensi Tanggal/
TTD
Label Jam
Kode Label I.

Observasi, Terapeutik, Edukasi dan Kolaborasi

Implementasi

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 EVALUASI KEPERAWATAN

Nama/Inisial : .........................................................................................................................................
Umur : .........................................................................................................................................
No. Register : .........................................................................................................................................
Diagnosa : .........................................................................................................................................

Tgl/Jam SOAP TTD

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 INTRA OPERASI

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

Operator : ..................................................................................
Keadaan umum : ..................................................................................
2. Tanda – tanda vital :
Suhu : ........................ oC
Nadi : ........................ x/menit
Respirasi : ........................ x/menit
Tekanan Darah : ........................ mmHg
3. Jenis Anastesi : ........................
4. Instrumen
......................................................................................................................................................................
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5. Catatan operasi
......................................................................................................................................................................
......................................................................................................................................................................
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Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 POST OPERASI
1. Operasi jam : ................................. WIB s/d .................................. WIB
2. Keadaan Umum
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
3. Tanda – tanda vital
S : .................................................... C N : ........................................ x/mnt
R : .................................................... x/mnt Tek. Darah : ........................................mmHg
4. Catatan
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 DIAGNOSA KEPERAWATAN
(*AKTUAL / RESIKO / PROMKES)

Nama/Inisial : .........................................................................................................................................
Umur : .........................................................................................................................................
No. Register : .........................................................................................................................................

Komponen Diagnosa Tanda dan Gejala

Mayor
Subjektif Objektif

Dibuktikan dengan Minor

Subjektif Objektif

Faktor Resiko (Untuk Dx Resiko)

Tanggal muncul Dx
Masalah (Problem)
Kode Masalah D.
Berhubungan dengan
(Penyebab)

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 LUARAN (*UTAMA / TAMBAHAN)
Komponen Luaran Keterangan

Diagnosa Keperawatan
Label
Kode Label L.
Ekspektasi *Meningkat / Menurun / Membaik
Target
Kriteria Hasil

INTERVENSI KEPERAWATAN
Komponen Intervensi Keterangan
Label
Kode Label I.

Observasi, Terapeutik, Edukasi dan Kolaborasi

Intervensi

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 IMPLEMENTASI KEPERAWATAN
Komponen
Keterangan
Intervensi Tanggal/
TTD
Label Jam
Kode Label I.

Observasi, Terapeutik, Edukasi dan Kolaborasi

Implementasi

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep

 EVALUASI KEPERAWATAN

Nama/Inisial : .........................................................................................................................................
Umur : .........................................................................................................................................
No. Register : .........................................................................................................................................
Diagnosa : .........................................................................................................................................

Tgl/Jam SOAP TTD

Tanda Tangan
Tanggal : ...................................................

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

Askep Ruang OK PJMA: Manggar Purwacaraka, S.Kep., Ns. M.Kep