ASUHAN KEPERAWATAN PERIOPERATIF

PENGKAJIAN
Hari/Tanggal : ............................................................................................
Ruang / Jam : ............................................................................................
Nama Mahasiswa :............................................................................................
NIM : ............................................................................................
A. Identitas Pasien
Nama :............................................................................................
Umur : ............................................................................................
No. RM :.............................................................................................
Jenis kelamin : ............................................................................................
Alamat : ............................................................................................
Pekerjaan : ............................................................................................
Diagnosa Medis : ............................................................................................
Tanggal masuk : ............................................................................................
B. Penanggung Jawab
Nama : ............................................................................................
Umur :............................................................................................
Alamat : ............................................................................................
Hubungan dg klien : ............................................................................................

PRE OPERATIF
A. DATA PASIEN
Keadaan Umum
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Keluhan Klien
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Tanda-tanda Vital :
TD :.................................................................
Nadi :.................................................................
RR :.................................................................
Suhu :.................................................................
Kesadaran:................................................................
Berat Badan :........................................................(Kg)
Pemeriksaan Fisik (IPPA & Data Fokus)
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A. Pemeriksaan Fisik (Data Fokus)

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A. Pemerikasaan Penunjang
Labratorium dan Radiologi
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B. Therapy
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C. Persiapan Operasi
Cairan parenteral:
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Baju operasi :
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Inform consent:
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Kebersihan Colon / Blader:
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D. ANALISA DATA (Pre Operatif)

Data Fokus
Etiologi Masalah

E. Diagnosa Keperawatan
1. ............................................................................................................

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2. ............................................................................................................

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 F. INTERVENSI KEPERAWATAN
NO Diagnosa Tujuan dan Kriteria Intervensi Implementasi Evaluasi
Keperawatan Hasil
INTRA OPERASI
A. Persiapan pasien di meja operasi
1. Jenis Anestesi
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2. Tanda-tanda Vital :
TD :.................................................................
Nadi :.................................................................
RR :.................................................................
Suhu :.................................................................
Kesadaran.................................................................:
3. Set Alat Operasi
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4. Laporan Jalannya Operasi (Gambaran saat mulai operasi-
proses-selesei)
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B. ANALISA DATA (Intra Operatif)

Data Fokus
Etiologi Masalah

C. Diagnosa Keperawatan
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2. ............................................................................................................

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3. ............................................................................................................

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 D. INTERVENSI KEPERAWATAN
NO Diagnosa Tujuan dan Kriteria Intervensi Implementasi Evaluasi
Keperawatan Hasil
POST OPERASI
B. Keadaan Umum
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C. Tanda-tanda Vital :
TD :.................................................................
Nadi :.................................................................
RR :.................................................................
Suhu :.................................................................
Kesadaran:................................................................
D. Pemeriksaan Fisik (Data Fokus)
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E. ANALISA DATA (Intra Operatif)

Data Fokus
Etiologi Masalah
F. Diagnosa Keperawatan
1. ............................................................................................................

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2. ............................................................................................................

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3. ............................................................................................................

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 G. INTERVENSI KEPERAWATAN
NO Diagnosa Tujuan dan Kriteria Intervensi Implementasi Evaluasi
Keperawatan Hasil