Professional Documents
Culture Documents
KAMAR OPERASI
Nama Mahasiswa
Tempat Praktik
Hari/Tanggal
Pembimbing
: Reka Mardiana
: Ruang OK Lt.3 RSUD Koja
:
: Ns.Ai Siti Sutilah, S.Kep
A. Identitas Pasien
Nama Pasien
:........................................................................................................
Usia
:...............................................................................................
.........
Agama
:...............................................................................................
.........
Diagnosa Medis
:........................................................................................................
B. Asuhan Keperawatan
1. Fase Preoperasi
a. Jenis Operasi
Cito
Elektif
b. Tindakan operasi
:........................................................................................................
c. Status Puasa
:........................................................................................................
d. Surat Izin Operasi
:........................................................................................................
e. Riwayat Alergi
Ya
Tidak
:..........................(.........................)
HT
:..........................(.........................)
Trombosit:..........................(.........................)
Leukosit :..........................(.........................)
g. Tanda-tanda vital
TD
:.........................mmHg
:........................kali/menit
Nadi
:.........................kali/menit
2. Fase Intraoperasi
RR
Suhu :........................C
a. Status ASA
:...............................................................................
b. Jenis Anastesi
:...............................................................................
c. Obat Anastesi yang digunakan
:...............................................................................
d. Pendarahan
.......
:........................................................................
e. Cairan IV Line
:...............................................................................
f.
Jenis Sayatan
:...............................................................................
3. Fase Postoperasi
a. Post Anastesia Score
:...................................................................
b. Tanda-tanda vital
TD
:.........................mmHg
:........................kali/menit
Nadi
:.........................kali/menit
RR
Suhu :........................C