P3D ANESTESI MINGGU I (IGD/BLUE LINE)

NAMA :
NIM :

TANGGAL/HARI :
JAM :

STATUS PASIEN ANESTESI

Pasien:
MR:
KU:
Telaah:

Umur/Kelamin:
BB/TB (PBW):

RPT:
RPO:
Time Sequence:

Primary Survey
A: Airway:
Snooring:
Gurgling:
Crowing:
Lain:
B: RR:
x/i
SP/ST:
Lain:
C: Akral: (H/D) (M/P) (K/B) TD:
/
mmHg HR:
T/V:
T:
Lain:
D: Sens:
GCS:
(E /V /M ) Pupil:
RC: /
Lain:
E: Fx:
UOP:
Volume:
cc
Warna:
Lain:
Tindakan:

C-Spine:
SaO2:
x/i

reg/irreg:
:

mm/

mm

Hasil:

Secondary Survey
B1: Airway:
Snooring:

Gurgling:

RR:
x/i
SP/ST:
Crowing:
GL:

Alergi:

Asma:

Batuk:

Sesak:
Lain:
B2: Akral: (H/D) (M/P) (K/B) TD:
/
mmHg HR:
x/i
reg/irreg:
T/V:
T:
Lain:
B3: Sens:
GCS:
(E /V /M ) Pupil:
:
mm/
RC: /
Lain:
B4: UOP:
Volume:
cc
Warna:
Lain:
B5: Inspeksi:
Mual/Muntah:
Palpasi:
Makan/Minum terakhir:
Perkusi:
Lain:
Auskultasi:
B6: Oedem:
Lain:
Radiologi:

mm

CT Scan:
EKG/USG:
Histopatologi:
Laboratorium
Hb/Ht/Leu/Plt:
PT/APTT/TT/IN :
Ur/Cr/UA:
Na/K/Cl:
AGDA
pH:
PCO2:
PaO2:
Lain:

Albumin:
KGD:
Bil. Tot/Direk:
SGOT/SGPT/ALP:
SaO2:
HCO3:
BE:

Total CO2:
Interpretasi AGDA:

Status Dehidrasi
Turgor
Hemodinamik

Ringan 3 5 %
BB
Baik
Takikardia

Rasa haus
Soft tissue

Haus
Normal

Urine
Kesadaran
Kelas Dehidrasi:
Rehidrasi:

Normal
Baik

Sedang 6
8%BB

Hipotensi, nadi
lemah
Sangat haus
Lidah lunak,
keriput
Pekat
Gelisah

Berat > 10%BB

Tensi TTU/nadi TTB

Mata cowong,
sianosis
Oliguria

Status Perdarahan
Class I
Blood Loss
750
% blood loss
15%
Pulse Rate
< 100
Blood
Normal
Pressure
Pulse
N or
Pressure
Increased
Respiratory
14 20
Rate
Urine Output
>30
(cc/j)
Mental
Slightly
Status
anxious
Kelas Perdarahan:
Resusitasi Perdarahan:

Class II
750 1500
15 30%
>100
Normal

Class III
1500 2000
30 40 %
>120
Decreased

Class IV
2000
40%
>140
Decreased

Decreased

Decreased

Decreased

20 30

30 35

>35

20 30

5 15

Negligible

Mildly anxious

Anxious and
confused

Confused and
lethargic

Monitoring perdarahan dan balans cairan

Jam
Cairan
Kristaloid
Koloid
WB
PRC
FFP
Trombosi
t
UOP
Perdarah
an
Permasalahan:

Rencana:

Diketahui oleh,
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PPDS STASE IGD/BLUE LINE