DAFTAR ALAT DAN OBAT

BOX EMERGENCY DEWASA

OK/RR/ICU
ALAT
N
O
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37

NAMA ALAT
LARYINGOSCOPE SET DEWASA (MAC 1,2,3,4)
JACKSON REES BALON 2 L
MASKER KETAT NO 4
MASKER KETAT NO 5
OROFARINGEAL AIRWAY NO 7
OROFARINGEAL AIRWAY NO8
OROFARINGEAL AIRWAY NO9
OROFARINGEAL AIRWAY NO 10
OROFARINGEAL AIRWAY NO 11
PLESTER
STILET NO 4
SPUIT CUFF 20 CC
MAGYL FORCEP
ETT NO 6
ETT NO 6.5
ETT NO 7
ETT NO 7.5
ETT NO 8
STETOSKOP DEWASA
SATURASI OKSIGEN PORTABEL
BATERAI LARYNGOSCOPE UKURAN TANGGUNG
BATERAI SATURASI ALKALINE UKURAN AA
SPUIT 3CC
SPUIT 5 CC
SPUIT 10 CC
SPUIT 20 CC
THREE WAY STOPCOCK
BLOOD SET
INFUS SET
GUNTING
NGT NO 14
SURFLOW NO 16
SURFLOW NO 18
SURFLOW NO 20
SUCTION TUBE NO 12
ALCOHOL SWAB
HANDSCOON ON (PASANG)

JUMLAH
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
5
5
5
1
2
1
1
1
1
2
2
2
1
10
3

DAFTAR ALAT DAN OBAT

BOX EMERGENCY DEWASA
OK/RR/ICU
OBAT
N
O
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
25
26
27
28

NAMA OBAT
EPINEFRIN/ADRENALIN ( 1MG/CC, AMPUL 1 CC)
SULFAS ATROPIN (0.25 MG/CC, AMPUL 1 CC)
LIDOCAINE 2% (20 MG/CC, AMPUL 2 CC)
EFEDRIN (50 MG/CC, AMPUL 1 CC)
KETAMIN (50 MG/CC, VIAL 10 CC)
PROPOFOL (20 MG/CC, AMPUL 10 CC)
MIDAZOLAM (1 MG/CC, AMPUL 5 CC)
MORPHIN (10 MG/CC, AMPUL 1 CC)
DIAZEPAM (5 MG/CC, AMPUL 2 CC)
FENTANYL (50 MCG/CC, AMPUL 2 CC)
PETHIDINE ( 50 MG/CC, AMPUL 2 CC)
ATRACURIUM (10 MG/CC, AMPUL 5 CC)
ROCURONIUM (10 MG/CC, VIAL/AMPUL 5 CC)
PZ 100CC
RL 500 CC
WATER FOR INJECTION 25 CC
AMINOPHILLIN ( 24 MG/CC, AMPUL 10 CC)
DEXAMETASONE (5 MG/CC, AMPUL 1 CC)
CALSIUM GLUCONAS 10% (AMPUL, 10CC)
NATRIUM BICARBONAT/MEYLON (1 MEQ/CC, FLAC,
25CC)
D40% 25 CC
FUROSEMIDE (10MG/CC, AMPUL 25 CC)
DOPAMIN (40 MG/CC, AMPUL 5 CC)
DOBUTAMIN ( 50 MG/CC, AMPUL 5 CC)
NOREPINEPHRIN (1 MG/CC, AMPUL 4 CC)
AMIODARONE /TYARIT (50 MG/CC, AMPUL 3 CC)

JUMLAH
10
10
10
3
1
1
1
1
1
1
1
1
1
2
1
2
1
1
2
2
2
1
1
1
1
1

DAFTAR ALAT DAN OBAT

BOX EMERGENCY ANAK
OK/RR/ICU
ALAT
N
O
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
32
33
34
35
36
37
38
39

NAMA ALAT
LARYINGOSCOPE SET ANAK (MAC 0,1,2)
JACKSON REES BALON 0.5 L
MASKER KETAT NO 00
MASKER KETAT NO 0
MASKER KETAT NO 1
MASKER KETAT NO 2
OROFARINGEAL AIRWAY NO 4
OROFARINGEAL AIRWAY NO 5
OROFARINGEAL AIRWAY NO 6
PLESTER
STILET NO 2.0
SPUIT CUFF 20 CC
MAGYL FORCEP ANAK
ETT NO 2.5
ETT NO 3
ETT NO 3.5
ETT NO 4
ETT NO 4.5
STETOSKOP ANAK
SATURASI OKSIGEN PORTABEL
BATERAI LARYNGOSCOPE ALKALINE UKURAN AA
BATERAI SATURASI ALKALINE UKURAN AA
SPUIT 3CC
SPUIT 5 CC
SPUIT 10 CC
SPUIT 20 CC
THREE WAY STOPCOCK
BLOOD SET
INFUS SET PEDIATRIC
GUNTING
NGT NO 5
NGT NO 6
NGT NO 8
NGT NO 10
SURFLOW NO 26
SURFLOW NO 24
SURFLOW NO 22
SUCTION NO 6
SUCTION NO 8
SUCTION NO 10
ALCOHOL SWAB
HANDSCOON ON (PASANG)

JUMLAH
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
5
5
5
1
2
1
1
1
1
1
1
1
2
2
2
1
1
1
10
3

DAFTAR ALAT DAN OBAT

BOX EMERGENCY ANAK
OK/RR/ICU
OBAT
N
O
1
2
3
4
5
6
7
8
9
10
12
14
16
17
18
19
20
21
22
23
24
25
26
27

NAMA OBAT
EPINEFRIN/ADRENALIN ( 1MG/CC, AMPUL 1 CC)
SULFAS ATROPIN (0.25 MG/CC, AMPUL 1 CC)
LIDOCAINE 2% (20 MG/CC, AMPUL 2 CC)
EFEDRIN (50 MG/CC, AMPUL 1 CC)
KETAMIN (50 MG/CC, VIAL 10 CC)
PROPOFOL (20 MG/CC, AMPUL 10 CC)
MIDAZOLAM (1 MG/CC, AMPUL 5 CC)
MORPHIN (10 MG/CC, AMPUL 1 CC)
DIAZEPAM (5 MG/CC, AMPUL 2 CC)
FENTANYL (50 MCG/CC, AMPUL 2 CC)
ATRACURIUM (10 MG/CC, AMPUL 5 CC)
PZ 100CC
WATER FOR INJECTION 25 CC
AMINOPHILLIN ( 24 MG/CC, AMPUL 10 CC)
DEXAMETASONE (5 MG/CC, AMPUL 1 CC)
CALSIUM GLUCONAS 10% (AMPUL, 10CC)
NATRIUM BICARBONAT/MEYLON (1 MEQ/CC, FLAC,
25CC)
D40% 25 CC
FUROSEMIDE (10MG/CC, AMPUL 25 CC)
PHENOBARBITAL (100 MG/CC, AMPUL 2 CC)
FENITOIN (50 MG/CC, AMPUL 2CC)
DOPAMIN (40 MG/CC, AMPUL 5 CC)
DOBUTAMIN ( 50 MG/CC, AMPUL 5 CC)
D10% 500 CC

JUMLAH
10
10
10
3
1
1
1
1
1
1
1
2
2
1
1
2
2
2
1
1
1
1
1
1

KARTU PENGGUNAAN OBAT / ALAT

BOX EMERGENCY DEWASA

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

22
23
24
25
26
27
28
29
30
31
32
33
34
35

NAMA ALAT
LARYINGOSCOPE SET
DEWASA (MAC
1,2,3,4)
JACKSON REES
BALON 2 L
MASKER KETAT NO 4
MASKER KETAT NO 5
OROFARINGEAL
AIRWAY NO 7*
OROFARINGEAL
AIRWAY NO8*
OROFARINGEAL
AIRWAY NO9*
OROFARINGEAL
AIRWAY NO 10*
OROFARINGEAL
AIRWAY NO 11*
PLESTER
STILET NO 4
SPUIT CUFF 20 CC
MAGYL FORCEP
ETT NO 6*
ETT NO 6.5*
ETT NO 7*
ETT NO 7.5*
ETT NO 8*
STETOSKOP DEWASA
SATURASI OKSIGEN
PORTABEL
BATERAI
LARYNGOSCOPE
UKURAN TANGGUNG
BATERAI SATURASI
ALKALINE UKURAN AA
SPUIT 3CC*
SPUIT 5 CC*
SPUIT 10 CC*
SPUIT 20 CC*
THREE WAY
STOPCOCK*
BLOOD SET*
INFUS SET*
GUNTING
NGT NO 14*
SURFLOW NO 16*
SURFLOW NO 18*
SURFLOW NO 20*
SUCTION TUBE NO
12*

ALCOHOL SWAB*
HANDSCOON ON
(PASANG) *

10
3

* (single use)

TANGGAL :
NAMA PASIEN :
UMUR :
NO RM :
N
O
1

36
37

JUMLA
H
1

TERPA
KAI

N
O
1

2
1
1
1
1
1
1

4
5
6

1
1
1
1
1
1
1
1
1
1
1
1
1
2

2
5
5
5
1
2
1
1
1
1
2
2
2
1

8
9
10

11

12

13

14
15
16
17

18

19
20

NAMA OBAT
EPINEFRIN/ADRENALI
N ( 1MG/CC, AMPUL 1
CC)*
SULFAS ATROPIN
(0.25 MG/CC, AMPUL
1 CC) *
LIDOCAINE 2% (20
MG/CC, AMPUL 2 CC)
*
EFEDRIN (50 MG/CC,
AMPUL 1 CC) *
KETAMIN (50 MG/CC,
VIAL 10 CC) *
PROPOFOL (20
MG/CC, AMPUL 10
CC) *
MIDAZOLAM (1
MG/CC, AMPUL 5 CC)
*
MORPHIN (10 MG/CC,
AMPUL 1 CC) *
DIAZEPAM (5 MG/CC,
AMPUL 2 CC) *
FENTANYL (50
MCG/CC, AMPUL 2
CC) *
PETHIDINE ( 50
MG/CC, AMPUL 2 CC)
*
ATRACURIUM (10
MG/CC, AMPUL 5
CC) *
ROCURONIUM (10
MG/CC,
VIAL/AMPUL 5 CC)
*
PZ 100CC*
RL 500 CC*
WATER FOR
INJECTION 25 CC*
AMINOPHILLIN ( 24
MG/CC, AMPUL 10
CC) *
DEXAMETASONE (5
MG/CC, AMPUL 1 CC)
*
CALSIUM GLUCONAS
10% (AMPUL, 10CC) *
NATRIUM

JUMLA
H
10

10

10

3
1
1

1
1
1

2
1
2
1

2
2

TERPA
KAI

21
22

25
26

27

28

BICARBONAT/MEYLON
(1 MEQ/CC, FLAC,
25CC) *
D40% 25 CC*
FUROSEMIDE
(10MG/CC, AMPUL 25
CC) *
DOPAMIN (40 MG/CC,
AMPUL 5 CC) *
DOBUTAMIN ( 50
MG/CC, AMPUL 5 CC)
*
NOREPINEPHRIN (1
MG/CC, AMPUL 4 CC)
*
AMIODARONE /TYARIT
(50 MG/CC, AMPUL 3
CC) *

2
1

1
1

Sudah/belum terganti (resep)

Dokter:
Perawat :
Petugas Apotik :

KARTU PENGGUNAAN OBAT / ALAT

BOX EMERGENCY DEWASA

* (single use)

TANGGAL :
NAMA PASIEN :
UMUR :
NO RM :

N
O
1

N
O
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
32
33
34
35
36
37
38
39

NAMA ALAT
LARYINGOSCOPE SET
ANAK (MAC 0,1,2)
JACKSON REES BALON
0.5 L
MASKER KETAT NO 00
MASKER KETAT NO 0
MASKER KETAT NO 1
MASKER KETAT NO 2
OROFARINGEAL AIRWAY
NO 4*
OROFARINGEAL AIRWAY
NO 5*
OROFARINGEAL AIRWAY
NO 6*
PLESTER
STILET NO 2.0
SPUIT CUFF 20 CC
MAGYL FORCEP ANAK
ETT NO 2.5*
ETT NO 3*
ETT NO 3.5*
ETT NO 4*
ETT NO 4.5*
STETOSKOP ANAK
SATURASI OKSIGEN
PORTABEL
BATERAI LARYNGOSCOPE
ALKALINE UKURAN AA
BATERAI SATURASI
ALKALINE UKURAN AA
SPUIT 3CC*
SPUIT 5 CC*
SPUIT 10 CC*
SPUIT 20 CC*
THREE WAY STOPCOCK*
BLOOD SET*
INFUS SET PEDIATRIC*
GUNTING
NGT NO 5*
NGT NO 6*
NGT NO 8*
NGT NO 10*
SURFLOW NO 26*
SURFLOW NO 24*
SURFLOW NO 22*
SUCTION NO 6*
SUCTION NO 8*
SUCTION NO 10*
ALCOHOL SWAB*
HANDSCOON ON

JUM
LAH
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
5
5
5
1
2
1
1
1
1
1
1
1
2
2
2
1
1
1
10
3

TER
PAKAI

(PASANG) *

4
5
6

8
9
10

12

14
16
17

18
19
20

21
22

23

24

NAMA OBAT
EPINEFRIN/ADRENALI
N ( 1MG/CC, AMPUL 1
CC) *
SULFAS ATROPIN
(0.25 MG/CC, AMPUL
1 CC) *
LIDOCAINE 2% (20
MG/CC, AMPUL 2 CC)
*
EFEDRIN (50 MG/CC,
AMPUL 1 CC) *
KETAMIN (50 MG/CC,
VIAL 10 CC) *
PROPOFOL (20
MG/CC, AMPUL 10
CC) *
MIDAZOLAM (1
MG/CC, AMPUL 5 CC)
*
MORPHIN (10 MG/CC,
AMPUL 1 CC) *
DIAZEPAM (5 MG/CC,
AMPUL 2 CC) *
FENTANYL (50
MCG/CC, AMPUL 2
CC) *
ATRACURIUM (10
MG/CC, AMPUL 5
CC) *
PZ 100CC*
WATER FOR
INJECTION 25 CC*
AMINOPHILLIN ( 24
MG/CC, AMPUL 10
CC) *
DEXAMETASONE (5
MG/CC, AMPUL 1 CC)*
CALSIUM GLUCONAS
10% (AMPUL, 10CC) *
NATRIUM
BICARBONAT/MEYLON
(1 MEQ/CC, FLAC,
25CC) *
D40% 25 CC*
FUROSEMIDE
(10MG/CC, AMPUL 25
CC) *
PHENOBARBITAL
(100 MG/CC, AMPUL 2
CC) *
FENITOIN (50 MG/CC,

JUMLA
H
10

10

10

3
1
1

1
1
1

2
2
1

1
2
2

2
1

TERPA
KAI

25
26

27

AMPUL 2CC) *
DOPAMIN (40 MG/CC,
AMPUL 5 CC) *
DOBUTAMIN ( 50
MG/CC, AMPUL 5 CC)
*
D10% 500 CC*

1
1

Sudah/belum terganti (resep)

Dokter:
Perawat :
Petugas Apotik :