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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 : Jam Masuk : Tanggal Pengkajian : No. RM : Jenis Operasi : Diagnosa Medis : 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 : KELUHAN UTAMA Keluhan utama : …………………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………… RIWAYAT PENYAKIT SEKARANG Riwayat Penyakit Sekarang : ………………………………………………………………………………................................................... ....................... ……………………………………………………………………………………………………………........................................ ................................................................................. ................................................................................. ...................... ……………………………………………………………………………………………………………........................................ ................................................................................. STIKes Surya Mitra Husada Kediri

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Page 1: ners.stikesstrada.ac.idners.stikesstrada.ac.id/.../01/format-resume-operasi.docx · Web viewSTIKES SURYA MITRA HUSADA KEDIRI PROGRAM PENDIDIKAN PROFESI NERS ALAMAT : JLN. Manila No

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 : Jam Masuk :Tanggal Pengkajian : No. RM :Jenis Operasi : Diagnosa Medis :Jam Operasi :

IDENTITAS1. Nama Pasien :2. Umur :3. Gol. Darah :4. Suku/ Bangsa :5. Agama :6. Pendidikan :7. Pekerjaan :8. Alamat :9. Sumber Biaya :

KELUHAN UTAMAKeluhan utama : ………………………………………………………………………………………………………………………………

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RIWAYAT PENYAKIT SEKARANGRiwayat 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

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ANALISIS DATA PRE OP.

Hari/Tgl/ Jam

DATA ETIOLOGI MASALAH KEPERAWATAN

DIAGNOSA KEPERAWATAN PRE OP :………………………………………………………………………………..........................................................................

STIKes Surya Mitra Husada Kediri

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STIKes Surya Mitra Husada Kediri

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RENCANA INTERVENSI PRE OP.

No. Hari/ Tgl/ Jam DIAGNOSA KEPERAWATAN NOC

(Nursing Outcome Classification)NIC

(Nursing Intervention Classification)

STIKes Surya Mitra Husada Kediri

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IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/ Tgl/ Shift

No. Dx Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf

STIKes Surya Mitra Husada Kediri

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PERSIAPAN PASIEN OPERASI :………………………………………………………………………………..........................................................................

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PERSIAPAN ALAT

Alat streril Jumlah Alat Non Steril JumlahPre op. Post op. Pre op. Post op.

a. Tidak Habis Pakai

b. Habis Pakai

STIKes Surya Mitra Husada Kediri

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PELAKSANAAN OPERASI :………………………………………………………………………………..........................................................................

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STIKes Surya Mitra Husada Kediri

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EVALUASI Keadaan Umum : a. Kesadaran : Compos Mentis Apatis Somnolen Sopor Komab. GCS :

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)

STIKes Surya Mitra Husada Kediri

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Total

Tanggal : …………………………………….

Mahasiswa

(…………...………………)

STIKes Surya Mitra Husada Kediri


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