PROGRAM PENDIDIKAN PROFESI NERS STIKES WIDYAGAMA HUSADAFORMAT PENGKAJIAN PERIOPERATIF KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa:NIM:Tempat Pengkajian:Tanggal:

Identitas KlienNama:No.RM:

Umur:Pekerjaan:Jenis Kelamin:Status Perkawinan:Agama:Tanggal MRS:Pendidikan:Tanggal Pengkajian:Alamat:Sumber Informasi:

Riwayat KesehatanKeluhan utama

Riwayat penyakit sekarang

Riwayat penyakit dahulu

.Diagnosa medis pada saat MRS

Pemeriksaan Fisik

PREOPERASIKeluhan pada periode preoperasi:Tanda-tanda vital:

Analisa data:NoDataMasalahPenyebab

Implementasi dan EvaluasiNoDiagnosaImplementasiEvaluasi

INTRA OPERASIPersiapan alat dan ruanganAlat tidak steril:

Alat Steril:

Bahan Medis Habis Pakai:...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Set yang dipakai:

Persiapan Perawat

Persiapan Pasien.

Prosedur operasi.

.

.Evaluasi selama operasi

Analisa DataNoDataMasalahPenyebab

Implementasi dan Evaluasi

NoDiagnosaImplementasiEvaluasi

POST OPERASIKondisi Pasien di RR...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Analisa DataNoDataMasalahPenyebab

Implementasi dan EvaluasiNo DiagnosaImplementasiEvaluasi

Malang,

( )NIM