RSKGM FKG UI

LAPORAN ANASTESI LOKAL BEDAH MULUT MINOR

Nama :
............................................................
Umur :
..........................................................
.. L/P
No.RM :
Tanggal :
............................................................

Diagnosis prabedah : ............................................................................

............................................................ ........
. ............................................................................
Jenis Pembedahan : ........
............................................................ ............................................................................
.... ........
Diagnosis pasca bedah :
.........................................................
Dokter Gigi Spesialis Bedah Mulut : ............................................................................
............................. .........
Perawat Bedah : ............................................................................
............................................................ ..........
........
A. CEK LIST PERSIAPAN ANESTESI
□ Informed consent □ Obat-obatan Anestesia Lokal
□ Monitoring □ Obat-obatan Emergensi
Tekanan Darah : ..............................mmHg
Nadi : .................... x/mnt, reg/ireg/adekuat/inadekuat
B. PREMEDIKASI : Oral
Jam : .........................
Obat : ......................... Dosis : .......................
D. JENIS ANASTESI LOKAL :
□ Infiltrasi □ Blok anestesi
INSTRUKSI PASCA ANESTESI :
 Pemantauan kesadaran,tensi,nadi,respirasi setiap
: ..................
 Posisi pasien :
............................................................................
Dokter Gigi
 Pengelolaan nyeri :
....................................................................
 Penanganan mual muntah :
.......................................................
 Diet dan nutrisi :
........................................................................
(................................................)
 Obat-obatan lain :
......................................................................
 Lain-lain :
.............................................................................
.....