ASUHAN KEPERAWATAN PERIOPERATIF

I. PENGKAJIAN
A. PRE OPERASI/PRE MEDIKASI
1. Serah terima pasieb
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2. Identitas pasien
Nama : ………………………………….....
Umur : ………………………………….....
Alamat : ………………………………….....
Diagnosa Medis : ………………………………….....
Tindakan Op : ………………………………….....

3. Pemeriksaan Fisik/Psikologi
TTV : …………………………………....................
Reaksi Fisik : …………………………………....................
Reaksi Psikologi : …………………………………....................
Persiapan Operasi :
Informed Concent /ijin Anestesi Puasa Cukur

Pemeriksaan Lab Radiologi EKG

Pre Medikasi
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B. INTRA OPERASI
1. Kelengkapan Tim Operasi
Bedah ………………Anestesi ……………Jenis Anestesi ……………………….
2. Tanda daerah operasi lokasi…………………………………………………….......
3. Kelengkapan anestesi IV Line …………………………………………………......
Obat-obatan …………………………..................................
4. Riwayat asma/alergi ……………………………………..........................................
5. Posisi operasi ……………………………………………………………………….
6. Rencana dilakukan tindakan ……………………………………………….......…..
 7. Observasi tindakan operasi ………………………………………………………...
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8. Observasi tindakan anestesi ………………………………………………………..
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9. Pemeriksaan kelangkapan
Kasa ………………….Jarum ………………….Intrumen ………………….
10. Pemeriksaan cairan / jaringan tubuh : ada tidak ada

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C. POST OPERASI/PASCA OPERASI

1. Airway
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2. Breathing
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3. Circulasi
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4. Observasi RR
Steward scor Aidrete scor Bromage scor

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5. Serah terima pasien ………………………………………………………………...
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II. Analisa Data
A. Pre Operasi
DATA ETIOLOGI MASALAH

B. Intra Operasi
DATA ETIOLOGI MASALAH

C. Post Operasi
DATA ETIOLOGI MASALAH