PROGRAM STUDI PENDIDIKAN NERS

STIKES SURYA MITRA HUSADA KEDIRI

PROGRAM PENDIDIKAN PROFESI NERS
ALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama Mahasiswa

: ...

NIM

FORMAT RESUME KAMAR OPERASI

Tanggal MRS
Tanggal Pengkajian
Jenis Operasi
Jam Operasi

:
:
:
:

IDENTITAS
1. Nama Pasien :
2. Umur
:
3. Gol. Darah :
4. Suku/ Bangsa
5. Agama
:
6. Pendidikan :
7. Pekerjaan
:
8. Alamat
:
9. Sumber Biaya

Jam Masuk :
No. RM
Diagnosa Medis

:
:

KELUHAN UTAMA
Keluhan utama :

RIWAYAT PENYAKIT SEKARANG

Riwayat Penyakit Sekarang :
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OBSERVASI DAN PEMERIKSAAN FISIK

Tanda tanda vital
S:
N:
T:
RR :
Kesadaran
Compos Mentis
Apatis

Somnolen

Sopor

Koma

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STIKes Surya Mitra Husada Kediri

ANALISIS DATA PRE OP.

Hari/
Tgl/
Jam

DATA

ETIOLOGI

MASALAH
KEPERAWATAN

DIAGNOSA KEPERAWATAN PRE OP :

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STIKes Surya Mitra Husada Kediri

RENCANA INTERVENSI PRE OP.

No.

Hari/
Tgl/ Jam

DIAGNOSA KEPERAWATAN

NOC
(Nursing Outcome Classification)

NIC
(Nursing Intervention Classification)

STIKes Surya Mitra Husada Kediri

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
Tgl/
Shift

No.
Dx

Jam

Implementasi

Paraf

Jam

Evaluasi (SOAP)

Paraf

STIKes Surya Mitra Husada Kediri

PERSIAPAN PASIEN OPERASI :

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PERSIAPAN ALAT
Alat streril

Jumlah
Pre op. Post op.

Alat Non Steril

Jumlah
Pre op. Post op.

a. Tidak Habis Pakai

b. Habis Pakai

STIKes Surya Mitra Husada Kediri

PELAKSANAAN OPERASI :
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STIKes Surya Mitra Husada Kediri

EVALUASI
Keadaan Umum :
a. Kesadaran
:
b. GCS
:

Compos Mentis

Apatis

Somnolen

Sopor

Koma

Observasi Tanda-tanda Vital :

Menit ke-

Tekanan darah
(mmHg)

Nadi (kali/menit)

Respiratori rate
(kali/menit)

Suhu (0C)

Balance Cairan :
Menit Ke-

Intake

Jumlah (cc)

Output

Jumlah (cc)

Total

Tanggal : .
Mahasiswa

(...)

STIKes Surya Mitra Husada Kediri