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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 :
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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ANALISIS DATA PRE OP.
Hari/Tgl/ Jam
DATA ETIOLOGI MASALAH KEPERAWATAN
DIAGNOSA KEPERAWATAN PRE OP :………………………………………………………………………………..........................................................................
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RENCANA INTERVENSI PRE OP.
No. Hari/ Tgl/ Jam DIAGNOSA KEPERAWATAN NOC
(Nursing Outcome Classification)NIC
(Nursing Intervention Classification)
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IMPLEMENTASI DAN EVALUASI KEPERAWATAN
Hari/ Tgl/ Shift
No. Dx Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
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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
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PELAKSANAAN OPERASI :………………………………………………………………………………..........................................................................
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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
Total
Tanggal : …………………………………….
Mahasiswa
(…………...………………)
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