CATATAN PERAWAT DAN DAFTAR PERIKSA CEPAT PRABEDAH

Pre-Operative Assessment :
Date : ______________ Time : _____________ Alergies : _____________________________________________________
Level of Consciousness ____Alert _____ Letargic _____ Confused ______ Unconscous
Restraints in Place : ____No ____ Yes Type : ______________________________________________________________
Ability to Move Extremities : _____No Difficulties : ________ Other,Describe : ____________________________________
____________________________________________________________________________________________________
Skin : _____ Intact ______ Other,Describe : ________________________________________________________________
____________________________________________________________________________________________________
IV Therapy Site/Port-a-Cath : ___________________________________________________________________________
Solution Infusng : Type / Amount : ______________________________________________________________
Voided Last at : ___________ Am / PM _____ Foley Cathether in Place and Functioning

Pre Operative Check list :

___ Identification Bracelet on Patient ___ Medication Kardex ___ Blood Work Result in Chart
___ Dentures Removed ___ History & Physical ___ Chest EKG Report in Chart
___ Jewerly Removed / Secured ___ Surgical Permit ___ X-Ray Report in Chart
___ Loose Teeth ___ Blood Permit ___ Urinalysis Report (notify
___ Contact Lenses /Glasses Removed ___ Breast Surgery Permit ___ Anasthesia if unable to get reports
___ Hairpins, Make-up, Naipolish is ___ Medical Clearnce ___ Addressograph Plate
Removed / Sculptured Nails ( when ordered) ___ All Chart Forms Stamped
___ Prosthess ___________________ ___ Anasthesia Permit
____________________________
___ NPO after ______________________ AM / PM
___ Patient Instructed Not to Get OOB Without Assistance ___ Verbalized Understanding
___ Call Bell Wthin Reach. Patient Instructed on Use of Call System ___ Verbalized Understanding
___ Side Rails Up ____ Patient Verbalized Understanding of Patient Safety
Temp : _________ Pulse : __________ Resp : ___________ B/P : _____________
(1 Hour Before OR)

Pre-Op Med :
___ Pre-Op Meds Given as Ordered : __________________________________ Time : _________________________
___ Pre-Op Meds Not Ordered
___ Unable To Give Pre-Op Meds. “Please Notify Anasthesia if Unable to Give Pre-Med”
___ Notified : _____________________________________________________
___ Antibiotics Sent With Patient : ____________________________________

_______________________
RN Signature

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 CATATAN KEPERAWATAN INTRAOPERATIF

INTRA-OPERATIVE NURSING CARE

Nursing Diagnosis – Potential for Injury
Plan. A. Position Safety
Type of postion : _____ supine ______ prone ______ lateral ______ beach chair ______ lithothomy
Positioning aids :  arthroscopy leg holder  thermo mattress ( setting ____________)
 seat belt (where________________________)  fracture table
 sandbag (where ________________________)  headrest
 rolled sheet (where _____________________)  stirrups
 vacupak  Wilson frame
 pillow (where __________________________)  hand table
 rt. armboard  unaffected leg support
 lt. armboard  other
Circulatory supports: _____ TEDs ______ Ace bandages ______ sequental stocking ( setting _________)
B. Electro surgical unit safety : ______ ESU unit (number _______) _____ bipolar unit (number ________)
Grounding pad site ____________applied by ___________site : coag _______ cut ________ tested __________
C. Tourniquet Safety
tourniquet _____________ cuff site ________________ apllied by _________________
Time inflated ___________ pressure ________________time deflated ______________
D. Potential for Retained Foreign Body Counts perfomed by
 sponge count corret yes no _____________ / _______________
 needle, sharp corret yes no _____________/ ________________
 Instrument corret yes no _____________/ ________________
Goal – Patient will be at minimum risk for injury
Evaluation – Goal Achieved _____ yes _____ no comments _________________________________________________
R.N signature _______________________________________________
Nursing Diagnosis – Potential for Infection
Plan .A.Mantain sterile technique, instruments & supplies _____
B. Area shaved_____________________________by ____________________________________________________
C. Skin prep _______________________________by ____________________________________________________
_______________________________by ____________________________________________________
Goal – Patient will be at minimum riks of infection
Evaluation – All necesarry precaution taken ____ yes ____ no comments ________________________________________
R.N signature _____________________________________
Preoperative Diagnosis : ________________________________________________________________________________
____________________________________________________________________________________________________
Procedure : __________________________________________________________________________________________
____________________________________________________________________________________________________
Postoperative Diagnosis : _______________________________________________________________________________
____________________________________________________________________________________________________
x-ray ____ yes, ____ no
Anesthesia : ____ General ____ MAC ____ Block (type __________ ) ____ local ____ Spinal ____ Epidural
Anesthesiologist _________________ Anesthetist ______________

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 CATATAN KEPERAWATAN POST OPERATIF

Times : Patient in OR at ________________ Patient out at ______________ Surgeon ______________________________

Assistant ______________________________________ Other person in the room ________________________________
Scrub Nurses ______________________________________________ in _______ out _______
______________________________________________ in _______ out _______
______________________________________________ in _______ out _______
Circulating Nurses __________________________________________ in _______ out _______
__________________________________________ in _______ out _______
__________________________________________ in _______ out _______
Medication ordered and given : _________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Irrigation Solution : ___________________________________________________________________________________
Physician’s Siganture _____________________________________________________
Vital Sign during Local Anasthesia :

Time
Blood Pressure
Pulse
Respirations
Pulse Oximeter

POST-OP ASSESSMENT
Implants : _____ yes , _______ no, _______ recorded on progress notes, other ___________________________________
Drains : Packing : Dressing :  other
 panrose  chest tube  nasal  4x4s  xeroform
 T-Tube  Solcotrans  oral  nasal splint  adaptic
 sump  Hemovac  wound  band aids  brace
 Jackson Pratt  other ________  bias stockinette  webril
 urinary cathether _______________________________  Ace bandage  splint
_________________________________________________  foundation garment  cast
Wound Classification : ______ clean, ______- clean-contamined, _______ contamined, ______ infected
Skin condition : _____ good, _____ other, comment _________________________________________________________
Specimens : _____ yes, _____ no _________________________________________________________________________
____________________________________________________________________________________________________
Cultures : _____ yes, _____ no ___________________________________________________________________________
Patient discharged : ______ RR, ______ ICU, ______ room, ______ OP, report by __________________________________
via : ________ RR stretcher, ________ bed, ________ side rails up, _______ wheelchair, _______ ambulatory
Date : _________________ Signature of circulating nurse __________________________________Patient status _______

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 FORMAT PENGKAJIAN KEPERAWATAN GAWAT DARURAT

Identitas Klien
Nama : .......................................................................................................................................................
Usia : .......................................................................................................................................................
Jenis Kelamin : .......................................................................................................................................................
Agama : .......................................................................................................................................................
Alamat : .......................................................................................................................................................
Tanggal Masuk : .......................................................................................................................................................
No.MR : .......................................................................................................................................................
Diagnosa Medis : .......................................................................................................................................................
Keluhan Utama

Pengkajian Primer
Airway
Breathing
Circulation
Disability
Eksposure

Pengkajian Sekunder
Riwayat Kesehatan Sekarang

Riwayat Kesehatan Lalu

Riwayat Kesehatan Keluarga

Pengkajian Head to Toe

Kepala
Leher
Thorak
Abdomen
Ekstremitas
Integumen
Pemeriksaan Penunjang dan Terapi Medis
Radiologi Laboratorium Darah Pemeriksaan Lain Terapi Medis

CATATAN KEPERAWATAN KRITIS

NURSES NOTES
Pupils Output (medication,procedures, observations,
 LevelConscious
i.v, - time puncture mode and

Drainage
I.V/P.OFluids In
O2 locations)

Urine
Temp
Pulse
Time

Resp
Skin

B/P

Total Total Total

EMERGENCY DEPARTMENT CRITICAL CARE RECORD

ASSESSMENT IN ICU
SAMPLE CHARTING FOR HOSPICE PATIENT