DOKTER MUDA

FK UNILA-RSAY

FOLLOW UP PRE-OP VISITE ANASTESI

Nama
Umur
Alamat
Ruangan

: .................................
: .................................
: .................................
: .................................

No. MR
Diagnosa
Operasi
Dokter

: .........................................
: .........................................
: .........................................
: ........................................

SUBJEKTIF
Keluhan
:
Riwayat HT (....), Riwayat DM (....), Riwayat Asma (....), Riwayat Alerg makanan/obat (....), Riwayat
gangguan pembekuan darah(....), Riwayat anastesi sebelumnya Regional anastesi/general anastesi.
Tgl..........., Batuk/pilek (....), riwayat pemakaian obat-obatan(....)
OBJEKTIF
Airway
:
Jalan nafas bersih (....), mallampati 1/2/3/4, Tiro-Mental Distance(TMD) .5cm (...), Buka mulut 3 jari
(....), gigi goyang, ompong, palsu(.....), perbesaran tiroid (.....), deviasi trakea (....)
Hasil Rontgen : .........................................................................................................................................
Breathing
:
Vesikuler (...../....),wheezing (..../....), rhonki (..../....), sesak (..../....), ekspansi paru simetris (..../....)
Circulation
:
S1/S2 Murni Irreguler/reguler, Gallop (.....), murmur (..../....), CRT <2 detik/lebih, sianosis (.....)
Hasil Laboratorium :
HB : ......... HT : .............. Leukosit : ............. Trombosit : .................. Golongan Darah : A/ B/ O/ AB,
GDS : ........., SGOT/SGPT : ...../...... HbsAg : ............. Ureum : ............ Kreatinin : .............. Natrium :
............ Kalium : .............. Calsium : ............... EKG : ............................................................................
Disability
:
GCS : .................................... Kesadaran : ............................. KU : .........................................
Tanda Vital
:
TD : ............. mmHg, N : ........................ x/m, RR : .............x/m, T : ................. 0C BB : ...........kg
ASSESMENT :
ASA I/ II/ III/ IV/ V/ E, General Anastesi ( Intubasi/ LMA/ TIVA/ Face Mask), Regional Anastesi
(Sub arachnoid block/ epidural/ lokal)
PLANNING :
Puasa ..........jam, pasang infus ........tpm, inform consent ..............
Kebutuhan cairan ..........................
Maintenance
= ..........x........(BB) =
Pengganti puasa
= .........x.........(M) =
Stressoperasi
= ........x..........(BB) =
Total
=
Pemberian jam I, (1/2 PP)+M+SO
=
Pemberian jam II,(1/4 PP)+M+SO
=
Lain-Lain

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