ASSESSMENT OF SURGICAL PERIOPERATIF

Student’s Name : Fenny Rahmanoor Astuti

NIM : 1614401320202
Date & Time of Assessment : February 13, 2018 (08.45 WITA)

I. ASSESSMENT
1. CLIENT’S IDENTITY
a. Name : Nn. R
b. Date of Birth/ Age : 22 Juny 1998 / 18 years old
c. Religion : Islam
d. Education : Senior High School
e. Address : Banua Anyar
f. NRM : 27-48-xx
g. Medic Diagnosis : Tongsilitis Hipertropi Kronis
2. FAMILY’S IDENTITY
a. Name :
b. Age :
c. Religion :
d. Education :
e. Occupation :
f. Relationship with client’s :
Patient Origin : □ Outpatient Inpatient □ Reference
A. PRE OPERATION
1. Main Complaint : client said pain when swallow
2. History of disease : □ DM □ Asma □ Hepatitis □ Jantung □ Hypertention □ HIV
Nothing
3. History of Surgery/anesthesia : □ Yes No
4. History of Alergies : □ Yes, .................. No
 5. Type of Surgery : Tongsilictomy (TE)
6. VS : Temp : 36,5℃, HR : 80x/mnt, RR : 20x/mnt, BP : 120/90 mmHg
7. Height/Weight : 150cm / 45kg
8. Blood Type : O Rhesus :
HISTORY OF PSYCHOSOCIAL/SPIRITUAL
9. Emotional State
Quiet □ confused □ Cooperatif □ No Cooperatif □ Cry □ Pull Away
10. The level of Anxiety : □ No Anxiety Anxiety
11. Scale of Anxiety: □ 0 = No Anxiety
1 = Expressing of Anxiety
□ 2 = High Level of Attention
□ 3 = Anxiety doesn’t focus
□ 4 = Simpate-adrenal Response
□ 5 = Panic
Scale of Pain by VAS ( Visual Analog Scale )

No Pain Mild Pain Moderate Pain Severe Pain Very Painful Pain isn’t Intolerable
□ 0-1 □ 2-3 □4-5 6-7 □ 8-9 □ 10
 Normal
Yes No If abnormal, describe

Head
12. The secondary survey, do it head to toe in priority :
Neck Tongsilitis Hipertropi Kronis

Chest

Abdoment

Genitalia

Integumen

Extrimity

13. Result of Support Examination

14. Laboratorium :
Parameter Result Unit Normal Range
WBC (Leukosit) 10.9 + 10ˆ3/uL 4.8 – 10.8
RBC (Eritrosit) 4.24 10ˆ6/uL 4.2 – 5.4
HGB (Hemoglobin) 12.2 g/dL 12 - 15
HCT (Hematokrit) 36.8 % 37 – 47
MCV 86.8 fL 79 – 99
MCH 28.8 pg 27 – 31
MCHC 33.2 g/dl 33 - 37
PLT (Trombosit) 205 10ˆ3/uL 150 – 450
 RDW 13.2 % 11.5 – 14.5
PDW 11.7 fL 9 17
MPV 9.8 fL 9 – 13
P-LCR 23.7 % 13 – 43
NEUT% 59 % 50 – 70
LYMPH% 30 % 25 – 40
MXD% 11 % 25 – 30
NEUT# 6.4 10ˆ3/uL 2 – 7.7
LYMPH# 3.3 10ˆ3/uL 0.8 – 4
MXD# 1.2 10ˆ3/uL 2 - 7.7
CT 4.00
BT 1.30

B. INTRA OPERATION
1. Time of Starting Anesthesia : 09.25 WITA
2. Time of Starting Surgery : 09.45 WITA
3. Type of Anesthesia :
□Spinal General anesthesia □ Local □ Nervus blok □……………
4. Position of Surgery :
On his back □ litotomy □ knee chees □ lateral : □ right □ left
□ others......
5. Anesthesia Record : Observation Vital Signs
6. Installation Tools :
Airway : ETT no : 6,5 □ LMA no:........ □ OPA
□ O2 Nasal
7. VS : Temp ℃, HR 97x/mnt, □ Palpable □ Strong □ Weak □ Regular □
Irregular, RR x/mnt, BP 109/62 mmHg, Saturation O2 98%
 8. The secondary survey, do it head to toe in priority :
Normal
Yes No If Abnormal, decribe

Head

Neck Tongsilitis Hipertropi Kronis

Chest

Abdomen

Genitalia

Integument

Extremity

Total of income fluid

Infusion : 500 cc of Asering
Tranfusion : cc

Total of outcome fluid

Urine : cc
Bleeding : cc

Balance of fluid : cc
C. POST OPERASI
1. Patient is moved to :
 □ ICU/PICU/NICU, WITA
Recovery Room (RR): 11.00 WITA
2. The complaint in RR : □ Nausea □ Vomiting □ Dizziness Wound pain
surgery □ The leg feels numbness □ Chills □ Others…..
3. General Condition : Good □ Moderate □ Severe
4. VS : Temp 35℃, P 80x/mnt, RR 20x/mnt, BP 110/90 mmHg, Sat O2 100%
5. Awareness : □CM Apatis □ Somnolen □ Soporo □ Coma
6. The secondary survey, do it head to toe in priority :
Normal
Yes No If Abnormal, decribe

Head

Neck Tongsilitis Hipertropi Kronis

Chest

Abdomen

Genitalia

Integument

Extremity

Scale of Pain by VAS ( Visual Analog Scale )

No Pain Mild Pain Moderate Pain Severe Pain Very Painful Pain isn’t Intolerable
□ 0-1 □ 2-3 □4-5 6-7 □ 8-9 □ 10
II. DATA ANALYSIS
Symptom Problem Etiologi
Pre Operasi: 1. Anxiety 1. Surgery Process
DS : client said she feel pain in 2. Acute Pain 2. Agent Injury Biologies
her throat when swallow.
P : pain when swallowing

Q ; pressing

R : disappeared

S : scale 7 (severe pain)

T : when swallow

Client said she anxious about

the operation because she
never do
DO : client look withstand pain
when swallow, client look
understand when a nurse
describe about her operation,
general condition is good.
Vital signs : Temp : 36,5℃,
HR : 80x/mnt, RR : 20x/mnt,
BP : 120/90 mmHg
Height/Weight : 150cm / 45kg
 Intra Operasi: 1. Risk of ineffective 1. Anesthesia process
DO : client look using ETT no airway clearance
6.5
Client performed surgery in the
mouth more precisely in her
tonsils
Post Operation 1. Risk of Hypothermia 1. Neuromuscular trauma
DO: factor and cold
Client look shivering environment
Client look groaning
Vital Signs
T : 35.0 oC,
P : 80 x/minute,
RR : 20 x/minute,
BP : 110/90 MmHg,
Saturasi O2 : 98%

III. NURSING DIAGNOSIS

a. Pre operasi :
1) Anxiety r/t surgery process
2) Acute Pain r/t agent injury biologies
b. Intra Operasi :
1) Risk of ineffective airway clearance r/t process of anesthesia
c. Post Operasi :
1) Risk of Hypothermia r/t Neuromuscular trauma factor and cold environment
2) Risk of Injury r/t Post Anesthesia
IV. NURSING INTERVENTION ( Including pre, intra and post operation)
Num Diagnosis Purpose
1 Anxiety r/t NOC
surgery process Anxiety Control
Criteria Result:
client cooperative, able to
identify and control
anxious with calm body
language, vital normal sign
2 Acute Pain r/t NOC
agent injury  Pain Level,
biologies  Pain control
 Comfort level
The Criteria Results :
 Able to control the pain
(know the causes of
pain, being able to use  Observations of nonverbal
the method
nonfarmakologi
reduce pain, seek help)
 Reported that the pain
was reduced with the use
of pain management
 Able to recognize pain
Intervention
NIC :
Anxiety Reduction
 Use a comprehensive
identification and approach
 Explain all the procedures that
will be done
 Give factual information about
the diagnosis
 Accompany clients during the
operation room and create a
comfortable confidence
NIC
Pain Management
 Do pain study comprehensively
include the location,
characteristics, duration,
frequency and quality factor of
precipitation
reactions and discomfort
to  Use of therapeutic
communication techniques to
figure out the patient's pain
experience
 Review the culture that
influences the response of pain
 (intensity, frequency,  Evaluation of the experience of
scale and signs of pain) the pain of the past
 · Declare a sense of  A joint evaluation of the patient
comfort after the pain is and other health teams about
reduced Ialu period pain control
ineffectiveness
 Select and do the handling of
pain (Pharmacology,
Pharmacology and inter
personal)
 Review the type and source of
pain to determine intervention
 Monitor patient acceptance of
pain management
Analgesic Administration
 Specify the location,
characteristics, qualities, and
degrees of pain before
dispensing
 Check the instructions of your
doctor about the type of drug,
dosage, and frequency
 Check the history of allergy
 Select the required analgesic or
a combination of an analgesic
when awarding more than one
 Select the option type and
severity-dependent analgesic
 pain
 Determine analgesic selections,
the route of the grant, and the
optimal dose
3 Risk of NOC: NIC
ineffective  And Respiratory status:  Respiratory monitoring
airway Ventilation  Monitor rate, rhythm, depth, and
clearance r/t  Respiratory status: respiration
process of Airway patency  Notice the chest movement
anesthesia The Criteria Result : symmetrical, observe, use of
 Demonstrate effective accessory muscles, muscle
cough and the sound of retraksi supraclavicular, and
the breath that is clean, interkostal
no cyanosis and dyspneu  Monitor additional breath
(able to excrete sputum, sounds
breathe with ease, there's  Monitor the pattern of breath:
no pursed lips) bradypnea, tachypnea,
 show the way the breath hyperventilasi, breath, breath
of a patent (the client kussmaul cheyne-stokes, biot's
does not feel suffocated, breath, apnea, and Utah.
the rhythm of breath,
respiratory frequency in
the normal range, there is
no abnormal breath
sounds)
 is able to identify and
prevent factors that
cause.
  O2 Saturation in the
normal range
4 Risk of NOC : NIC :
Hypothermia thermoregulation thermoregulation control
related to Criteria Result:  Monitor vital sign
Neuromuscular balance of body  Regulation of temperature by
trauma factor temperature within normal maintaining normal body
and cold limits temperature range (air warmer)
environment  Blanket the client
V. IMPLEMENTATION
Day and Hours Diagnosis Implementation Signature
Date
Tuesday, 09.00 Anxiety related to 1. Using a
February surgery process comprehensive
13th 2018 identification and
approach
2. Explain all the
procedures that
will be done
3. Giving factual
information about
the diagnosis
4. Accompany clients
during the
operation room and
create a
comfortable
confidence
 Acute Pain r/t 1. pain study
agent injury comprehensively
biologies include the location,
characteristics,
duration, frequency
and quality factor of
precipitation
2. Observations of
nonverbal reactions
and discomfort
3. Using of therapeutic
communication
techniques to figure
out the patient's pain
experience
4. Review the type and
source of pain to
determine
intervention
5. Checking the history
of allergy
Tuesday, 12.45 Risk of 1. Controling operating
February ineffective room entry procedure
13th 2018 airway clearance for clients / officers
2. Limiting the number
of personnel in the
operating room
 3. Controling the
sterility of the
operating room and
equipment used
hand washing
surgery, surgical
wear, wearing of
toileting gloves,
installation of
surgical procedures
4. Monitoring
Respiratory
Tuesday, 13.00 Risk of 1. Monitoring vital sign
February Hypothermia 2. Regulation of
13th 2018 related to temperature by
Neuromuscular maintaining normal
trauma factor and body temperature
cold environment range (air warmer
3. Blanket the client
VI. EVALUATION
Day and Hours Diagnosis Evaluation
Date
Tuesday, 09.10 Anxiety related to S : The client says no more
February Social role change anxiety
13th 2018 and permanent
O : Client look calm
disability
Client look understand with a
nurse describing about her
 surgery

BP:130/90 MmHg,
P:70 x/minute,
R: 18 x/minute,
T:36,2 oC

A : The issue is resolved

P : Stop Intervention

Acute Pain r/t agent S : The client says still pain

injury biologies
 P : pain when swallowing

 Q ; pressing

 R : disappeared

 S : scale 7 (severe pain)

 T : when swallow

O : Client look withstand pain

when swallow
General condition is good
 BP:120/90 MmHg,
 P:80 x/minute,
 R: 20 x/minute,
 T:36,5 oC
A : Pain not resolved
P : Stop Intervention
Tuesday, 12.45 Risk of ineffective S:-
February airway clearance
O : Client hasn’t ineffective
13th 2018
 airway clearance

A : ineffective airway clearance

risk issues do not occur

P : Stop Intervention

Tuesday, 13.00 Risk of Hypothermia S : the client says not cold

February related to
O : the client is not shivering
13th 2018 Neuromuscular
Vital Signs
trauma factor and cold
T : 36,0 oC,
environment
P : 75 x/minute,
RR : 20 x/minute,
BP : 120/80 MmHg,
Saturasi O2 : 98%
A : the issue is resolved

P : Stop intervention
 ASSESSMENT OF SURGICAL PERIOPERATIF

Student’s Name : Fenny Rahmanoor Astuti

NIM : 1614401320202
Date & Time of Assessment : February 13, 2018 (10.40 WITA)

I. ASSESSMENT
1. CLIENT’S IDENTITY
a. Name : Mr. R
b. Date of Birth/Age : 29 July 1974 / 43 years old
c. Religion : Islam
d. Education : Senior High School
e. Address : Jl. Gerilya
f. NRM : 37-59-xx
g. Medical Diagnosis : HIL ( Hernia Inguinalis Lateralis)

2. FAMILY’S IDENTITY
a. Name : Mr. Z
b. Age : 65 years old
c. Religion : Islam
d. Education : S1
e. Occupation : swasta
f. Relationship with client : Uncle
Patient Origin : □ Outpatient Inpatient □ Reference
A. PRE OPERASI
1. Main Complaint : client said he has hernia or intestine down to the scrotum
2. History of Disease : □ DM □ Asma □ Hepatitis □ Jantung □ Hipertensi □ HIV
Nothing
3. History of surgery/anesthesia : □ Yes No
 4. History of Alergies : □ Yes, ................. No
5. Type of Surgery : Herniotomy
6. VS : Temp : 36,5℃, HR : 78x/mnt, RR : 18x/mnt,BP : 120/90 mmHg
7. Height/Weight : 168cm / 64kg
8. Blood Type : Rhesus :
HISTORY OF PSHYCOSOCIAL/SPIRITUAL
9. Emotional State
calm □ confused □ Cooperatif □ Noncooperatif □ Cry □ Pull away
15. The level of Anxiety : □ No Anxiety Anxiety
16. Scale of Anxiety: □ 0 = No Anxiety
1 = Expressing of Anxiety
□ 2 = High Level of Attention
□ 3 = Anxiety doesn’t focus
□ 4 = Simpate-adrenal Response
□ 5 = Panic
Scale of pain by VAS ( Visual Analog Scale )

Very Pain isn’t

No Pain Mild Pain Moderate Pain Severe Pain
Painful Intolerable
0-1 □ 2-3 □4-5 □ 6-7
□ 8-9 □ 10
17. The secondary survey, do it head to toe in priority :

Normal
Yes No Describe if abnormal

Head

Neck

Chest

Abdomen

Genitalia HIL (Hernia Inguinalis Lateralis)

Integument

Extremity

10. Result of supporting examination

11. Laboratory :
Parameter Result Unit Normal Range
MCHC 32.5 g/dL 33-37
NEUT% 48 % 50-70
LYMPH% 44 % 25-40
MXD# 0.6 10^3/uL 2-7.7
B. INTRA OPERASI
1. Time of Starting Anesthesia: 12.20 WITA
2. Time of Starting Surgery : 12.45 WITA
3. Type of Anesthesia : □Spinal □General anastesi Local □ Nervus blok
□……………
4. Position of Surgery :
On his back □ litotomy □ knee chees □ lateral : □ right □ left □ others......
 5. Anesthesia Record : Observation Vital Signs
6. Installation Tools :
Airway : □ETT no :…… □ LMA no:........ □ OPA □ O2 Nasal
7. VS : Temp ℃, P 80x/mnt, □ Palpable □ Strong □ Weak □ Regular □
Irregular, RR 20x/mnt, BP 146/90 mmHg, Saturation O2 99%
8. The secondary survey, do it head to toe in priority :
Normal
Yes No Describe if abnormal

Head

Neck

Chest

Abdomen

Genitalia HIL (Hernia Inguinalis Lateralis)

Integument

Extremity

 Total of income fluid

Infusion : 500 cc of Asering
Tranfusion : cc
 Total of outcome fluid
Urine : cc
Bleeding : cc
 Balance of fluid : cc
D. POST OPERASI
1. Patient is moved to :
□ ICU/PICU/NICU, WITA
Recovery Room (RR): 13.00 WITA
2. The complaint in RR : □ Nausea □ Vomiting □ Dizziness Wound pain
surgery □ The leg feels numbness □ Chills □ Others…..
3. General Condition : Good □ Moderate □ Severe
4. VS : Temp 36,5℃, P 80x/mnt, RR 20x/mnt, BP 120/90 mmHg, Sat O2 100%
5. Awareness : CM □ Apatis □ Somnolen □ Soporo □ Coma
6. The secondary survey, do it head to toe in priority :
Normal
Describe if abnormal
Yes No

Head

Neck

Chest

Abdomen

Genitalia HIL (Hernia Inguinalis Lateralis)

Integument

Extremity
 Scale of pain by VAS ( Visual Analog Scale )

No Pain Mild Pain Moderate Pain Severe Pain Very Painful Pain isn’t Intolerable
□ 0-1 2-3 □4-5 □ 6-7 □ 8-9 □ 10

II. ANALISA DATA

Symptom Problem Etiologi
PRE OPERATION Anxiety Social role change and
Subjective Data : permanent disability
The client said nervously
Objectibe Data :
clients sometimes look
thoughtful and anxiety
Vital Signs :
BP:130/90 MmHg,
P:70 x/minute,
R: 18 x/minute,
T:36,2 oC
INTRA OPERATION Risk of Infection
Subjective Data : -

Objective Data :
client performed surgery is
installation of GIPS in the left
hand
POST OPERATION Risk of Hypothermia Neuromuscular trauma factor
Subjective Data : and cold environment
Client says it is cold

Objective Data :
Client look shivering
Vital Signs
T : 36.0 oC,
P : 75 x/minute,
RR : 20 x/minute,
BP : 120/80 MmHg,
Saturasi O2 : 98%

III. NURSING DIAGNOSIS

PRE OPERATION
1. Anxiety related to Social role change and permanent disability

INTRA OPERATION
1. Risk of Infection

POST OPERATION
1. Hypothermia related to Neuromuscular trauma factor and cold environment

IV. NURSING INTERVENTION (Including pre, intra and post operation)

Num Diagnosis Purpose Intervention
1 Anxiety related to NOC: Anxiety Control NIC : Anxiety
Social role change and Criteria : client Reduction
permanent disability cooperative, able to
 identify and control 1. Use a
anxious with calm comprehensive
body language, vital identification
normal sign and approach
2. Explain all the
procedures that
will be done
3. Give factual
information
about the
diagnosis
4. Accompany
clients during
the operation
room and create
a comfortable
confidence
2 Risk of Infection NOC: Infection NIC : Infection
protection, management control
environment, host and 1. Control
agen control operating room
Criteria : controlled entry procedure
infection infections, for clients /
wounds and around officers
the net 2. Limit the
number of
personnel in the
operating room
 3. Control the
sterility of the
operating room
and equipment
used
hand washing
surgery, surgical
wear, wearing of
toileting gloves,
installation of
surgical
procedures
4. Do the wound
closure
according to the
procedure
3 Risk of Hypothermia NOC : NIC : thermoregulation
related to thermoregulation control
Neuromuscular trauma Criteria : balance of 1. Monitor vital
factor and cold body temperature sign
environment within normal limits 2. Regulation of
temperature by
maintaining
normal body
temperature
range (air
warmer)
 3. Blanket the
client

V. IMPLEMENTASI
Day and Hours Diagnosis Implementation Signature
Date
Tuesday, 11.30 Anxiety related to 5. Using a
February Social role comprehensive
13th 2018 change and identification and
permanent approach
disability 6. Explain all the
procedures that
will be done
7. Giving factual
information about
the diagnosis
8. Accompany clients
during the
operation room and
create a
comfortable
confidence
Tuesday, 12.45 Risk of Infection 5. Controling
February operating room
13th 2018 entry procedure for
clients / officers
6. Limiting the
number of
 personnel in the
operating room
7. Controling the
sterility of the
operating room and
equipment used
hand washing
surgery, surgical
wear, wearing of
toileting gloves,
installation of
surgical procedures
8. Doing the wound
closure according
to the procedure
Tuesday, 13.00 Risk of 4. Monitoring vital
February Hypothermia sign
13th 2018 related to 5. Regulation of
Neuromuscular temperature by
trauma factor and maintaining normal
cold environment body temperature
range (air warmer
6. Blanket the client

VI. EVALUATION :
Day and Hours Diagnosis Evaluation
Date
Tuesday, 11.30 Anxiety related to S : The client says no more
February Social role change anxiety
13th 2018 and permanent
disability
O : Client look calm

BP:130/90 MmHg,
P:70 x/minute,
R: 18 x/minute,
T:36,2 oC

A : The issue is resolved

P : Stop Intervention

Tuesday, 12.45 Risk of Infection S:-

February
13th 2018
O : Client are not infected

A : infectious risk issues do not

occur

P : Stop Intervention

Tuesday, 13.00 Risk of Hypothermia S : the client says not cold

February related to
O : the client is not shivering
th
13 2018 Neuromuscular
Vital Signs
trauma factor and cold
T : 36,0 oC,
environment P : 75 x/minute,
RR : 20 x/minute,
BP : 120/80 MmHg,
Saturasi O2 : 98%

A : the issue is resolved

P : Stop intervention
 FORMAT PENGKAJIAN PERIOPERATIF KAMAR BEDAH

Nama Mahasiswa : Fenny Rahmanoor Astuti

NIM : 1614401320202
Tgl & jam pengkajian : February 14, 2018 (08.35 WITA)

I. PENGKAJIAN
1. IDENTITAS PASIEN

a. Nama Pasien : An. R

b. Tgl lahir/ Umur : 21 January 2015 / 3 years old
c. Agama : Islam
d. Pendidikan :-
e. Alamat : Rawa Sari
f. No CM : 37-78-xx
g. Diagnosa Medis : STT Aurikula
2. IDENTITAS ORANG TUA/ PENANGGUNG JAWAB
a. Nama : Mrs. N
b. Umur : 33 years old
c. Agama : Islam
d. Pendidikan : SMK
e. Pekerjaan : Housewife
f. Hubungan dengan pasien : Mother
Asal pasien : □ Rawat Jalan Rawat Inap □ Rujukan

A. PRE OPERASI
1. Keluhan Utama : client’s mother said she has a lump in her right ear as big as
green beans
2. Riwayat Penyakit : □ DM □ Asma □ Hepatitis □ Jantung □ Hipertensi □ HIV
Tidak ada
 3. Riwayat Operasi/anestesi : □ Ada Tidak ada
4. Riwayat Alergi : □ Ada, sebutkan.................. Tidak ada
5. Jenis Operasi :
6. TTV : Suhu : 36℃, Nadi : 93x/mnt, Respirasi : 28x/mnt,TD : mmHg
7. TB/BB : cm / 11kg
8. Golongan Darah : Rhesus :
RIWAYAT PSIKOSOSIAL/SPIRITUAL
9. Status Emosional
□ Tenang □ Bingung □ Kooperatif □ Tidak Kooperatif Menangis
□ Menarik diri
10. Tingkat Kecemasan : □ Tidak Cemas Cemas
11. Skala Cemas : □0 = Tidak cemas
1 = Mengungkapkan kerisauan
□2 = Tingkat perhatian tinggi
□3 = Kerisauan tidak berfokus
□4 = Respon simpate-adrenal
□5 = Panik
Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
0-1 □ 2-3 □4-5 □6-7 □ 8-9 □ 10
12. Survey Sekunder, lakukan secara head to toe secara prioritas:

Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala STT Aurikula

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas

13. Hasil Data Penunjang

14. Laboratorium :
Parameter Result Unit Normal Range
WBC (Leukosit) 10ˆ3/uL 4.8 – 10.8
RBC (Eritrosit) 10ˆ6/uL 4.2 – 5.4
HGB (Hemoglobin) g/dL 12 - 15
HCT (Hematokrit) % 37 – 47
MCV fL 79 – 99
MCH pg 27 – 31
MCHC g/dl 33 - 37
PLT (Trombosit) 10ˆ3/uL 150 – 450
RDW % 11.5 – 14.5
PDW fL 9 17
 MPV fL 9 – 13
P-LCR % 13 – 43
NEUT% % 50 – 70
LYMPH% % 25 – 40
MXD% % 25 – 30
NEUT# 10ˆ3/uL 2 – 7.7
LYMPH# 10ˆ3/uL 0.8 – 4
MXD# 10ˆ3/uL 2 - 7.7
CT
BT

15. EKG

16. Rontgen :

17. USG :

18. Lain-lain :
B. INTRA OPERASI
1. Anastesi dimulai jam : 09.20 WITA
2. Pembedahan dimulai jam : 09.45 WITA
3. Jenis anastesi :
□Spinal Umum/general anastesi □ Lokal □ Nervus blok □……………
4. Posisi operasi :
Terlentang □ litotomi □ tengkurap/knee chees □ lateral : □ kanan □ kiri □
lainnya......
5. Catatan Anestesi : observation vital signs
6. Pemasangan alat-alat :
 Airway : □Terpasang ETT no :………. Terpasang LMA no: 1 □ OPA
□ O2 Nasal
7. TTV : Suhu ℃, Nadi 125x/mnt, Teraba □ kuat, □ Lemah, □ teratur, □ tidak
teratur, RR x/mnt, TD mmHg, Saturasi O2 100%
8. Survey Sekunder, lakukan secara head to toe secara prioritas
Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala STT Aurikula

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas

Total cairan masuk

Infus : 500 cc Asering
Tranfusi : cc

Total cairan keluar

Urine : cc
Perdarahan : cc

Balance cairan : cc
C. POST OPERASI
1. Pasien pindah ke :
□ Pindah ke ICU/PICU/NICU, jam Wib
RR jam 10.20 WITA
2. Keluhan saat di RR : □ Mual □ Muntah □pusing Nyeri luka operasi
□ Kaki terasa baal □ Menggigil □lainnya…..
3. Keadaan Umum : Baik □ Sedang □ Sakit berat
4. TTV : Suhu 36.5℃, Nadi 80x/mnt, RR 20x/mnt, TD 120/90 mmHg, Sat O2 100%
5. Kesadaran : □CM Apatis □ Somnolen □ Soporo □ Coma
6. Survey Sekunder, lakukan secara head to toe secara prioritas:
Normal
Jika Tidak normal, jelaskan
YA TIDAK
Kepala STT Aurikula

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas
 Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
0-1 □ 2-3 □4-5 □6-7 □ 8-9 □ 10

II. ANALISA DATA

Symptom Problem Etiologi
Pre Operasi:
1. Cemas
DS :
DO :

Intra Operasi:
1. Risk of jln nafas
DO :

Post Operasi:
1. Kerusakn integritas 1. Luka post op
DS
kulit
DO
2. Resti infeksi

3. nyeri

III. DIAGNOSA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :

IV. RENCANA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :

V. IMPLEMENTASI
Pre operasi :
Intra Operasi :
Post Operasi :

VI. EVALUASI :
Pre operasi :
S
O
A
P
Intra Operasi :
S
O
A
P
Post Operasi :
S
O
A
P
 FORMAT PENGKAJIAN PERIOPERATIF KAMAR BEDAH

Nama Mahasiswa : Fenny Rahmanoor Astuti

NIM : 1614401320202
Tgl & jam pengkajian : February 14, 2018 (08.35 WITA)

I. PENGKAJIAN
1. IDENTITAS PASIEN
1. Nama Pasien : Mr. B
2. Tgl lahir/ Umur : 12 February 1942 / years old
3. Agama : Islam
4. Pendidikan : Elementary School
5. Alamat :
6. No CM :
7. Diagnosa Medis :
2. IDENTITAS ORANG TUA/ PENANGGUNG JAWAB
g. Nama : Mrs. M
h. Umur : 37 years old
i. Agama : Islam
j. Pendidikan : SMK
k. Pekerjaan : Swasta
l. Hubungan dengan pasien : Daughter
Asal pasien : Rawat Jalan □ Rawat Inap □ Rujukan

A. PRE OPERASI

1. Keluhan Utama : client said she has a catarac in her left eye
2. Riwayat Penyakit : □ DM □ Asma □ Hepatitis Jantung □ Hipertensi □ HIV
□Tidak ada
3. Riwayat Operasi/anestesi : Ada □ Tidak ada
 4. Riwayat Alergi : □ Ada, sebutkan.................. Tidak ada
5. Jenis Operasi : Fharul Enulsifikasi
6. TTV : Suhu : 36.5℃, Nadi : 79x/mnt, Respirasi : 20x/mnt,TD : 130/90mmHg
7. TB/BB : cm / 45kg
8. Golongan Darah : B Rhesus :
RIWAYAT PSIKOSOSIAL/SPIRITUAL
9. Status Emosional
Tenang □ Bingung □ Kooperatif □ Tidak Kooperatif □ Menangis □ Menarik diri
10. Tingkat Kecemasan : Tidak Cemas □Cemas
11. Skala Cemas: 0 = Tidak cemas
□ 1 = Mengungkapkan kerisauan
□ 2 = Tingkat perhatian tinggi
□ 3 = Kerisauan tidak berfokus
□ 4 = Respon simpate-adrenal
□ 5 = Panik
Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
0-1 □ 2-3 □4-5 □6-7 □ 8-9 □ 10
 12. Survey Sekunder, lakukan secara head to toe secara prioritas:

Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas

13. Hasil Data Penunjang

14. Laboratorium :
Parameter Result Unit Normal Range
WBC (Leukosit) 10ˆ3/uL 4.8 – 10.8
RBC (Eritrosit) 10ˆ6/uL 4.2 – 5.4
HGB (Hemoglobin) g/dL 12 - 15
HCT (Hematokrit) % 37 – 47
MCV fL 79 – 99
MCH pg 27 – 31
MCHC g/dl 33 - 37
PLT (Trombosit) 10ˆ3/uL 150 – 450
RDW % 11.5 – 14.5
PDW fL 9 17
MPV fL 9 – 13
 P-LCR % 13 – 43
NEUT% % 50 – 70
LYMPH% % 25 – 40
MXD% % 25 – 30
NEUT# 10ˆ3/uL 2 – 7.7
LYMPH# 10ˆ3/uL 0.8 – 4
MXD# 10ˆ3/uL 2 - 7.7
CT
BT

15. EKG

16. Rontgen :

17. USG :

18. Lain-lain :

B. INTRA OPERASI
1. Anastesi dimulai jam : 09.55 WITA
2. Pembedahan dimulai jam : 10.20 WITA
3. Jenis anastesi : □Spinal □Umum/general anastesi Lokal □ Nervus blok
□……………
4. Posisi operasi :
Terlentang □ litotomi □ tengkurap/knee chees □ lateral : □ kanan □ kiri
□ lainnya......
5. Catatan Anestesi : observation vital signs
6. Pemasangan alat-alat :
 Airway : □Terpasang ETT no :………. Terpasang LMA no: 1 □ OPA
□ O2 Nasal
7. TTV : Suhu ℃, Nadi x/mnt, Teraba □ kuat, □ Lemah, □ teratur, □ tidak
teratur, RR x/mnt, TD mmHg, Saturasi O2 %
8. Survey Sekunder, lakukan secara head to toe secara prioritas
Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas

Total cairan masuk

Infus : cc
Tranfusi : cc

Total cairan keluar

Urine : cc
Perdarahan : cc

Balance cairan : cc
C. POST OPERASI
1. Pasien pindah ke :
□ Pindah ke ICU/PICU/NICU, jam Wib
RR jam 10.50 WITA
2. Keluhan saat di RR :□ Mual □ Muntah □pusing Nyeri luka operasi
□ Kaki terasa baal □ Menggigil □lainnya…..
3. Keadaan Umum : Baik □ Sedang □ Sakit berat
4. TTV : Suhu 36℃, Nadi 82x/mnt, RR 20x/mnt, TD 130/90 mmHg, Sat O2 %
5. Kesadaran : CM □ Apatis □ Somnolen □ Soporo □ Coma
6. Survey Sekunder, lakukan secara head to toe secara prioritas:
Normal
Jika Tidak normal, jelaskan
YA TIDAK
Kepala

Leher

Dada

Abdomen

Genitalia

Integumen

Ekstremitas
 Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
0-1 □ 2-3 □4-5 □6-7 □ 8-9 □ 10

II. ANALISA DATA

Symptom Problem Etiologi
Pre Operasi:
1. Gg persepsi sensori-
DS :
perseptual penglihtan
DO :

Intra Operasi:
1. Resti infeksi 1. Luka insisi
DO :

Post Operasi:
1. Rsk infeksi 1. Fek samping
DS
prosedur invasive
2. Resti cedera
DO
2. Keterbtsn
3. nyeri
pnglihatan

3. Post op

III. DIAGNOSA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :

IV. RENCANA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :

V. IMPLEMENTASI
Pre operasi :
Intra Operasi :
Post Operasi :

VI. EVALUASI :
Pre operasi :
S
O
A
P
Intra Operasi :
S
O
A
P
Post Operasi :
S
O
A
P
 FORMAT PENGKAJIAN PERIOPERATIF KAMAR BEDAH

Nama Mahasiswa : Fenny Rahmanoor Astuti

NIM : 1614401320202
Tgl & jam pengkajian : February 15, 2018 (08.35 WITA)

I. PENGKAJIAN

1. IDENTITAS PASIEN
1. Nama Pasien : An. Ra
2. Tgl lahir/ Umur : 16 February 2011 / 6 years old
3. Agama : Islam
4. Pendidikan : Elementary School
5. Alamat : Handil Bakti Indah
6. No CM : 37-86-xx
7. Diagnosa Medis : Close Fraktur Radius Ulna

2. IDENTITAS ORANG TUA/ PENANGGUNG JAWAB

1. Nama : Mrs. R
2. Umur : 40 years old
3. Agama : Islam
4. Pendidikan : S1
5. Pekerjaan : PNS
6. Hubungan dengan pasien : Mother
Asal pasien : □ Rawat Jalan Rawat Inap □ Rujukan
A. PRE OPERASI
1. Keluhan Utama : client’s mother said client fall from the chair in the mosque
2. Riwayat Penyakit : □ DM □ Asma □ Hepatitis □ Jantung □ Hipertensi □ HIV
Tidak ada
3. Riwayat Operasi/anestesi : □Ada Tidak ada
 4. Riwayat Alergi : □ Ada, sebutkan.................. Tidak ada
5. Jenis Operasi : GIPS
6. TTV : Suhu : 36.5℃, Nadi : 89x/mnt, Respirasi : 29x/mnt,TD : mmHg
7. TB/BB : cm / 23kg
8. Golongan Darah : Rhesus :
RIWAYAT PSIKOSOSIAL/SPIRITUAL
9. Status Emosional
Tenang □ Bingung □ Kooperatif □ Tidak Kooperatif □ Menangis
□ Menarik diri
10. Tingkat Kecemasan : □Tidak Cemas Cemas
11. Skala Cemas: □ 0 = Tidak cemas
1 = Mengungkapkan kerisauan
□ 2 = Tingkat perhatian tinggi
□ 3 = Kerisauan tidak berfokus
□ 4 = Respon simpate-adrenal
□ 5 = Panik
Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
□ 0-1 2-3 □4-5 □6-7 □ 8-9 □ 10
12. Survey Sekunder, lakukan secara head to toe secara prioritas:

Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala

Leher

Dada

Abdomen

Genitalia

Integumen

Close fraktur radius ulna in the upper right

Ekstremitas
extremity

13. Hasil Data Penunjang

14. Laboratorium :
Parameter Result Unit Normal Range
WBC (Leukosit) 10ˆ3/uL 4.8 – 10.8
RBC (Eritrosit) 10ˆ6/uL 4.2 – 5.4
HGB (Hemoglobin) g/dL 12 - 15
HCT (Hematokrit) % 37 – 47
MCV fL 79 – 99
MCH pg 27 – 31
MCHC g/dl 33 - 37
PLT (Trombosit) 10ˆ3/uL 150 – 450
RDW % 11.5 – 14.5
PDW fL 9 17
 MPV fL 9 – 13
P-LCR % 13 – 43
NEUT% % 50 – 70
LYMPH% % 25 – 40
MXD% % 25 – 30
NEUT# 10ˆ3/uL 2 – 7.7
LYMPH# 10ˆ3/uL 0.8 – 4
MXD# 10ˆ3/uL 2 - 7.7
CT
BT

15. EKG

16. Rontgen :

17. USG :

18. Lain-lain :

B. INTRA OPERASI
1. Anastesi dimulai jam : 09.15 WITA
2. Pembedahan dimulai jam : 09.25 WITA
3. Jenis anastesi : □Spinal Umum/general anastesi □ Lokal □ Nervus blok
□……………
4. Posisi operasi : Terlentang □ litotomi □ tengkurap/knee chees □ lateral : □ kanan □
kiri □ lainnya......
5. Catatan Anestesi : observation vital signs
6. Pemasangan alat-alat :
 Airway : □Terpasang ETT no :………. Terpasang LMA no: 1 □ OPA
□ O2 Nasal sungkup
7. TTV : Suhu ℃, Nadi 121x/mnt, Teraba □ kuat, □ Lemah, □ teratur, □ tidak
teratur, RR x/mnt, TD mmHg, Saturasi O2 100%
8. Survey Sekunder, lakukan secara head to toe secara prioritas
Normal
YA TIDAK Jika Tidak normal, jelaskan

Kepala

Leher

Dada

Abdomen

Genitalia

Integumen

Close fraktur radius ulna in the upper right

Ekstremitas
extremity

Total cairan masuk

Infus : 500 cc Asering
Tranfusi : cc

Total cairan keluar

Urine : cc
Perdarahan : cc

Balance cairan : cc
C. POST OPERASI
1. Pasien pindah ke :
□ Pindah ke ICU/PICU/NICU, jam Wib
RR jam 09.50 WITA
2. Keluhan saat di RR : □ Mual □ Muntah □pusing Nyeri luka operasi
□ Kaki terasa baal □ Menggigil □lainnya…..
3. Keadaan Umum : Baik □ Sedang □ Sakit berat
4. TTV : Suhu 36,5℃, Nadi 130x/mnt, RR 22x/mnt, TD mmHg, Sat O2 100%
5. Kesadaran : □ CM □ Apatis Somnolen □ Soporo □ Coma
6. Survey Sekunder, lakukan secara head to toe secara prioritas:
Normal
Jika Tidak normal, jelaskan
YA TIDAK
Kepala

Leher

Dada

Abdomen

Genitalia

Integumen
Close fraktur radius ulna in the upper right
Ekstremitas
extremity
 Skala Nyeri menurut VAS ( Visual Analog Scale )

Tidak nyeri Nyeri ringan Nyeri sedang Nyeri berat Sangat Nyeri Nyeri tak Tertahan
□0-1 □ 2-3 □4-5 6-7 □ 8-9 □ 10

II. ANALISA DATA

Symptom Problem Etiologi
Pre Operasi:
1. Cemas
DS :
2. Nyeri
DO :
3.
Intra Operasi:
1. Tdak efektif jln nafas
DO :
2.
Post Operasi:
1. Nyeri
DS
2.
DO

III. DIAGNOSA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :

IV. RENCANA KEPERAWATAN

Pre operasi :
Intra Operasi :
Post Operasi :
 V. IMPLEMENTASI
Pre operasi :
Intra Operasi :
Post Operasi :

VI. EVALUASI :
Pre operasi :
S
O
A
P
Intra Operasi :
S
O
A
P
Post Operasi :
S
O
A
P