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FOLLOW UP PRE ANESTESI

Tanggal Visite :...............

Tgl R. Operasi:..

Nama
Umur
Alamat
Ruangan
Tgl MRS
.
S)

:......................................................... L/P
:.................... Thn, Inform Cons: + / :...............................................................
:...............................................................
:..

No. MR
Diagnosa
R. Tind
Operator
Anestator

O)

Airway:
Jalan nafas bersih (......), Malapati 1 / 2 / 3 / 4, TMD 7 cm (.......), Buka mulut 3 jari (.......)
Gigi goyang / ompong / palsu, Pembesaran kelenjar tiroid (.......), Deviasi trakhea (...............)
Hasil Rontgen:...........................................................................................................................

:......................................
:.
:.
: Dr
: Dr

Keluhan......................................................................................................................................
Riw. HT (.......), Riw. DM (.......), Riw. Asma (.......), Riw. Alergi (mak / obat)...........................
Riw. Anest sblmnya: RA / GA, tanggal..........................................Batuk / Pilek, Haid (........)

Breathing:
Vesikuler (........), Wheezing (........), Ronkhi (.........), Sesak (........), Ekspansi paru Sim / tidak
Circulation:
S1/S2 murni (.......), Suara jtg tambahan (.........), Reguler / Irreguler, Akral HKM / HKP,
Hasil lab: Hb...............WBC................HCT..............PLT..................CT/BT............../................
Golda A / B / AB / O, GDS................SGOT/PT................./..................HbsAg.........................
Ureum...............Creatinin.....................Natrium.....................Kalium.............Mag.....................
Hasil EKG..................................................................................................................................
Disability:
GCS............................, Kesadaran.........................................K/U.............................................
Tanda Vital: TD........./............mmHg, N...........x/mnt, RR.........x/mnt, BB......Kg, SB....C
A)

P)

ASA I / II / III / IV / V E
GA (Intubasi / LMA / TIVA / Face Mask)
Puasa......................................
Pasang infus...........................
Inform consent........................
Kebutuhan cairan:
M
= 2 x.............(BB)
=
PP
= 8 x......................(M)
=
SO
= 4 / 6 / 8 x............(BB)
=
Total
=
Pemberian jam I, (1/2 PP)+M+SO
=
Pemberian jam II/III, (1/4PP)+M+SO
=
Perdarahan, EBV 70 BB...........................

RA (SAB / Epidural / Lokal)


Premedikasi :
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- ..
- ..
Induksi :
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SYRJDN -JEFTA, D IV KAR


2012