SEKOLAH TINGGI ILMU KESEHATAN “HUTAMA ABDI HUSADA” Ijin Pendirian Mendiknas RI RI Nomor : 113/D/O/2009 113/D/O/2009
Jl. Dr. Wahidin Sudiro Husodo Telp./Fax: 0355-322738
Tulungagung 66224
Alamat E-mail :
[email protected]
FORMAT PENGKAJIAN DI KAMAR OPERASI NO. MR :
Diagnosa medis : ………..............…………… ……….......... ....…………… Tanggal pengkajian : ………... ………...………………….. ………………….. Jam : …………... …………...………………. ……………….
Dikirim tanggal : …..........………………. Dikirim ruangan : ………..........…………. 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: ……………............ ……………........................ .......................... ......................... ........................ ......................... ....................... ........................ ......................... ......................... ................. .... ....................... .................................... ......................... ......................... ......................... ........................ .............. .. ……………………………………… 2. Saat pengkajian: ....................... .................................... ......................... ......................... ......................... ......................... ........................ ........................ ......................... ............................. ....................... ...... ....................... .................................... ......................... ......................... ......................... ........................ ........................ ........................ ............................. ............................. ................... ....... . 3. Riwayat Penyakit (PORST): Di rumah: ……………............................................................................................................ ................... ....................... .................................... ......................... ........................... .......................... ........................ ............. ……………………………………… Saat pengkajian: ....................... .................................... ......................... ......................... ......................... ........................ ........................ ........................ ............................. ............................ ................... ........ ....................... .................................... ......................... ........................... .......................... ....................... ......................... ......................... ........................... .......................... ................. ...... 4. Upaya Yang Telah Dilakukan : …………………………………………………………………………………………………. 5. Operasi Yang Pernah Dilakukan : …………………………………………………………………………………………………. C. PEMERIKSAAN FISIK 1. Keadaan umum 2. Tanda – Tanda – tanda tanda vital Suhu : ………….. C Nadi : ………....... ………....... X / Mnt Respirasi : ………….. X / Mnt Tekanan Darah : .................. .......... ........ mmHg Catatan 1 | STIKES HAH 2016
................................................................................................................................................. ................................................................................................................................................. 3. Body system (review of system a. Pernafasan (B1 / Breathing ) .......................................................................................................................................... .......................................................................................................................................... b. Cardiovaskuler (B2 / Bleeding ) .......................................................................................................................................... .......................................................................................................................................... c. Persyarafan (B3 / Brain) .......................................................................................................................................... .......................................................................................................................................... d. Perkemihan – Eliminasi uri (B4 / Bladder ) .......................................................................................................................................... .......................................................................................................................................... e. Pencernaan – Eliminasi alvi (B5 / Bowel ) .......................................................................................................................................... .......................................................................................................................................... f. Tulang – otot – integument (B6 / Bone) .......................................................................................................................................... .......................................................................................................................................... g. Sistem indokrin .......................................................................................................................................... .......................................................................................................................................... h. Reproduksi .......................................................................................................................................... .......................................................................................................................................... i. Psikososial .......................................................................................................................................... .......................................................................................................................................... j. Spiritual .......................................................................................................................................... .......................................................................................................................................... D. PEMERIKASAAN PENUNJANG ………………………………………………………………………………………………….………… ………………………………………………………………………………........……………………… …………………………………………………………………...………………………………………… ....................................................................................................................................................... ..................................…………………………………………………………………………………… E. ANALISA DATA PRE OPERASI S
2 | STIKES HAH 2016
E
P
F.
DIAGNOSA KEPERAWATAN ………………….............................................................................................................................. ......................................... ……………………………………………………………………………..... ………………………………………………………………………………………………….………… G. INTERVENSI 1. Tujuan : ................................................................................................................................................. .................………………………………………………………………………………………….... 2. Kriteria Hasil : ………………………………………………………………………………………………….……… …………………………………………………………………………………………....................... ................................................................................................................................................. 3. Intervensi: ………………………………………………………………………………………………….……… ................................................................................................................................................. ................................................................................................................................................. .....................…………………………………………………………………………………………. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ............................ …………………………………………………………………………………… …… H. IMPLEMENTASI …………………………………………………………………………………………….……………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………….…………………………………………………………………… …………………………….……………………………………………………………………………… ………………….………………………………………………………………………………………… ……….………………………………………………………………………………………………….… ……………………………………………………………………………………………….…………… …………………………………………………………………………………….……………………… ……………………………………………………………………….................................................... …………………………………………………………………………………………………. I. EVALUASI ………………………………………………………………………………………………….………… ……………………………………………………………………………………….…………………… …………………………………………………………………………….……………………………… ……………………………………………………………………………………………………………… …………………………………………………….……………………………………………………… ……………………………………….…………………………………………………………………… …………………………….……………………………………………………………………………… ………………….………………………………………………………………………………………… ……….………………………………………………………………………………………………….… ……………………………………………………………………………………………….…………… ………………………………………………………………………………………………………………
INTRA OPERASI 1. Operasi jam : ……………………. WIB s/d jam …………………… WIB Operator : ………………………………………………………… Keadaan umum .........……………………………………………………………………………………………… 3. Tanda – tanda vital Suhu : ………….. C Nadi : ………....... X / Mnt Respirasi : ………….. X / Mnt Tekanan Darah : .................. mmHg 4. Catatan operasi ………………………………………………………………………………………………............................ .................………………………………………………………………………………………...................... 3 | STIKES HAH 2016
...................………………………………………………………………………….………………………… ………………………………………………………………………….……………………………………… ………………………………………………………………….……………………………………………… ………………………………………………………….……………………………………………………… ………………………………………………….……………………………………………………………… ………………………………………….……………………………………………………………………… ………………………………….……………………………………………………………………………… ………………………….……………………………………………………………………………………… ………………….……………………………………………………………………………………………… ………….……………………………………………………………………………………………………… ….………………………………………………………………………………………………………….…… ………………………………………………………………………………………………….……………… ………………………………………………………………………………………….……………………… ………………………………………………………………………………….……………………………… ………………………………………………………………………….……………………………………… ………………………………………………………………….……………………………………………… ………………………………………………………….……………………………………………………… ………………………………………………….……………………………………………………………… ………………………………………….……………………………………………………………………… ………………………………….……………………………………………………………………………… ………………………….……………………………………………………………………………………… ………………….……………………………………………………………………………………………… ………….……………………………………………………………………………………………………… 5. Instrumen ………………………………………………………………………………………………............................ .................………………………………………………………………………………………...................... ...................………………………………………………………………………….………………………… ………………………………………………………………………….……………………………………… ………………………………………………………………….……………………………………………… ………………………………………………………….……………………………………………………… ………………………………………………….……………………………………………………………… ………………………………………….……………………………………………………………………… ………………………………….……………………………………………………………………………… ………………………….……………………………………………………………………………………… ………………….……………………………………………………………………………………………… ………….……………………………………………………………………………………………………… ….………………………………………………………………………………………………………….…… ………………………………………………………………………………………………….……………… ………………………………………………………………………………………….……………………… ………………………………………………………………………………….……………………………… ………………………………………………………………………….……………………………………… ………………………………………………………………….……………………………………………… ………………………………………………………….……………………………………………………… ………………………………………………….……………………………………………………………… ………………………………………….……………………………………………………………………… ………………………………….……………………………………………………………………………… ………………………….……………………………………………………………………………………… ………………….………………………………………………………………………………………………
POST OPERASI 1. Operasi jam : ……………………. WIB s/d jam …………………… WIB 2. Keadaan Umum : ………………………………………………………………………………..………………………… ……………………………………………………..…………………………………………………… …………………………...……………………………………………………………………………... 3. Tanda – tanda vital S : ……………. C N : ………….. x/mnt R : ……………. x/mnt Tek. Darah : …………….mmHg 4. Catatan ………………………………………………………………………………………………............................ .................………………………………………………………………………………………...................... ...................………………………………………………………………………….………………………… 4 | STIKES HAH 2016
………………………………………………………………………….……………………………………… ………………………………………………………………….……………………………………………… ……………….………………………………………………………………………………………………… ……….…………………………………………………………………………………………………………. …………………………………………………………………………………………………………………… ……………………………………………………………………………………………….………………… …………………………………………………………………………………….
A. ANALISA DATA POST OPERASI S
E
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B. DIAGNOSA KEPERAWATAN ………………………………………………………………………………………………….………… ……………………………………………………………………………………….…………………… ……………………………………………………………………………. C. INTERVENSI Tujuan ………………………………………………………………………………………………….………… ……………………………………………………………………………………….…………………… ……………………………………………………………………………. Kriteria Hasil ………………………………………………………………………………………………….………… …………………………………………………………………………………….……………………… ………………………………………………………………………….………………………………… ……………………………………………………………… Intervensi ………………………………………………………………………………………………….………… …………………………………………………………………………………….……………………… ………………………………………………………………………….………………………………… …………………………………………………………….……………………………………………… ………………………………………………….………………………………………………………… ……………………………………….…………………………………………………………………… ………………………….………………………………………………………………………………… ……………….…………………………………………………………………………………………… …….………………………………………………………………………………………………….…… …………………………………………………………………………………………….……………… …………………………………………………………………………………. D. IMPLEMENTASI 5 | STIKES HAH 2016
E.
………………………………………………………………………………………………….………… ……………………………………………………………………………………….…………………… ………………………………………………………………………….………………………………… …………………………………………………………….……………………………………………… ………………………………………………….………………………………………………………… ……………………………………….…………………………………………………………………… ………………………….………………………………………………………………………………… ……………….…………………………………………………………………………………………… …….………………………………………………………………………………………………….…… ………………………………………………………………………………………. …………………………………………………………………………………………………. EVALUASI ………………………………………………………………………………………………….………… ……………………………………………………………………………………….…………………… …………………………………………………………………………….……………………………… ………………………………………………………………….………………………………………… ……………………………………………………….…………………………………………………… …………………………………………….……………………………………………………………… ………………………………….………………………………………………………………………… ……………………….…………………………………………………………………………………… …………….……………………………………………………………………………………………… ….……………………………………………………………………………………………….………… …………………………………………………………………………………….……………………… ………………………………………………………………………….………………………………… ……………………………………………………………….…………………………………………… …………………………………………………….……………………………………………………… ………………………………………….………………………………………………………………… ……………………………….…………………………………………………………………………… …………………….……………………………………………………………………………………… ………….…………………………………………………………………………………………………. ………………………………………………………………………………………………….………… ………………………………………………………………………………….………………………… ……………………………………………………………………………………………………………… ……………………………………………………. Tanggal
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Nama Perawat : ........................
6 | STIKES HAH 2016
Tanda Tangan
