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FORMAT RESUME OPERATING ROOMPRE OPERATIVE (Penerimaan pasien dari perawat ruangan pada perawat OR) I. Pengkajian Identitas Pasien (Verifikasi nama pasien dan tanggal lahirnya, Lakukan pemeriksaan untuk memastikan bahwa semua data pada Medical Record sesuai dengan patient’s wristband - gelang id pasien dan dokumentasi keperawatan) Nama: Usia: Diagnosa medis: Preoperative Diagnosis: Inform Consent: (Valid atau tidak) TTV: pemeriksaan termutakhir di ruangan Kaji warna dan integritas kulit Riwayat kesehatan yang dapat berpengaruh terhadap hasil operasi ( Diabetes) Tingkat pengetahuan pasien terhadap operasi yang akan dialaminya dan komplikasi yang mungkin terjadi. NPO status (kapan terakhir pasien makan atau minum peroral) Therapy obat yang terakhir dikonsumsi pasien di pagi hari sebelum operasi dan waktu pemberiannya. Kaji Allergi dan reaksi yang dialami pasien saat allergi all ergi Kaji pemasangan metal implants, terutama AICD’s dan pacemakers. Jika ada chemotherapy atau therapy radiasi lainnya, kaji kapan terakhir dilakukan oleh pasien.
Premedikasi: Preoperative inspection:Observasi area yang akan di operasi (skin preparation), barang – barang barang berharga (perhiasan), underwear, pemakaian gigi palsu agar diamankan jika masih ada yg tertinggal di pasien. Hasil Laboratorium darah yang terbaru (Hb, CT/BT) IV Line: (Ukuran IV kanula dan pemakaian three ways) Tingkat Kecemasan:Trusted by over 1 million membersTry Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.Trusted by over 1 million membersTry Scribd FREE for 30 days to access over 125 million titles without ads or interruptions!
Start Free Trial Cancel Anytime.Diagnosa The nursing diagnosis is written in a manner that helps determine outcomes. Some nursing diagnoses for surgical patients are: oo ooImpaired gas exchange related to anesthesia, pain, and surgical procedure Activity intolerance related to pain Anxiety related to anesthesia, pain, disease, surgical procedure Alteration in nutrition less than body requirements related to NPO status.Planning Intervensi keperawatan pada pasien di ruang operasi berfokus pada patient safety. Perawat menyiapkan supply yang dibutuhkan untuk pelaksanaan prosedur operasi sesuai dengan kebutuhan surgeon, memposisikan perlengkapan prosedur operasi (suction, electrocautery, dsb), dan supply khusus yang diperlukan sesuai kebutuhan pasien saat dilakukan pengkajian. Preparation assures that the nurse will be able to remain in the surgical suite as much as possible to provide care for the patient. The nurse leaving the room is avoided as much as possible, but unforeseen circumstances may require the nurse to leave to obtain equipment or supplies.
When the patient is brought to the operating room and transferred to operating table, patient comfort and safety are the priority. The nurse provides warmed blankets for the patient and applies the safety strap across the patient. The surgeon is called to the OR suite and the “time out” is performed with the patient pat ient participating. Items verified in the time out are the patient’s name, date of birth, allergies, procedure to be performed, correctness of consent, site marking, if applicable, and any antibiotics to be given within one hour prior to incision. The patient is instructed to take deep breaths before and after anesthesia to maintain oxygen saturation above 95%. Strict aseptic and sterile technique are maintained throughout the surgical procedure to reduce the risk for postoperative infection. The nurse remains at the bedside during the induction phase and holds the patient’s hand to help reduce anxiety.
The patient is reassured as needed.Nursing Intervention The circulating nurse and the scrub nurse/technician work as a team to protect the sterility of the operative field by maintaining constant surveillance. Any breaks in sterile technique, such as a tear in the surgeon’s glove, glove, are remedied immediately.Trusted by over 1 million membersTry Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.induced and the anesthesia provider releases the care of the patient to the surgical team. At this time a foley catheter will be placed, if indicated, using aseptic technique.
The patient will be positioned and all pressure points will be padded to prevent altered skin integrity. The surgical skin prep is then performed aseptically and allowed to dry before placement of the surgical drapes. Fumes from a wet surgical prep can form pockets of gas that have the potential to be ignited by a spark from the electrocautery used in surgery. Prior to the surgical incision, the anesthesia provider initiates the infusion of the antibiotic ordered by the surgeon. A preincision verification performed by the circulating nurse rechecks the patient’s name, the surgical procedure, the site/side of the procedure, the antibiotic infusion has started, and the prep is dry.
Evaluation The circulating nurse monitors the patient vigilantly during the course of the perioperative phase which includes preoperative, operative, and postoperative stages of surgery. He/she is responsible for the smooth transition for the patient between these phases. Evaluation of the patient’s response to the surgical intervention is ongoing and continuous. Have the surgical outcomes been met? If not, reassessment takes place to plan further.Conclusion The patient under anesthesia is totally dependent on the surgical team for their well-being.
The perioperative nurse advocates for the patient. He/she is their voice during the surgical intervention. Whether scrubbing, circulating, or supervising other team members, the perioperative nurse is always aware of the total environment, as well as the patient's reaction to the environment and the care given during all three phases of surgical intervention. The perioperative nurse is knowledgeable about aseptic technique, patient safety, legal aspects of nursing, and management of nursing activities associated with the specific surgical procedure being performed. OR nursing is unique: it provides a specialty service during the perioperative period that stresses the need for continuity of care and respect for the individuality of the patient's needs.Beth, RN, CNOR ASN Degree with Honors from St. Petersburg College, St. Petersburg, FL Staff RNII.
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INTRAOPERATIVE Persiapan obat anesthesiaTrusted by over 1 million membersTry Scribd FREE for 30 days to access over 125 million titles without ads or interruptions!
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