PEMERINTAH KABUPATEN KEDIRI

RSUD SIMPANG LIMA GUMUL KEDIRI

LABEL PASIEN
ASSESMENT PRE ANESTESI

Pre Induksi

1. Pre Medikasi : ________________________________________________ Jam :_____________WIB

TD:_______mmHg Nadi:______x/menit Respirasi:______x/menit Suhu :_____oC BB:____Kg

2. Induksi : Safol / Ketamin / dl = _____________________________________________Terang

Pelumpuh Otot = ___________________________________________________________________

3. Teknik Anestesi

( ) Regional : SAB / Epidural : Obat :__________________________________

( ) Intravena : Drip / Intermiten : Obat :__________________________________

( ) Inhalasi : Semi Open/ Semi Close/Close

: Masker / NT / ETT no_______Cuff__________Mayo______________

: Respirasi : Spontan : Spontan / Assisted / Kendali

: Obat : Isoflurane / N2O / O2

( ) Posisi : Terlentang / Tengkurap / Miring / Lithotomy

Kediri, __________________________
dr Anestesi

(__________________________)
 MONITORING INTRA SEDASI

S R N T.D Waktu
- - - 240
41 36 - 220
40 32 - 200
39 28 - 180
38 24 - 160
37 20 180 140
36 16 160 120
35 12 140 100
34 8 120 80
33 - 100 60
32 - 80 40
31 - 60 20
30 - 40 0
29 -
28 -
Scala Nyeri
Aldrette Score
Bromage Score
Infus

Urine

Muntah

INSTRUKSI PASCA SEDASI

MONITOR : Nafas : ..............., Tensi : ..............., Nadi:............., Suhu: ..........., Setiap : ............,
Selama; ......
Infus :

_________________________________________________________________
Antibiotik :
Obat-obatan lain :

_________________________________________________________________
Bila Mual/Muntah :

_________________________________________________________________
Bila Kesakitan :
(Skala Nyeri ≥ 3)

Minum / Makan : _________________________________________________________________

Lain-lain :

AHLI ANESTESIOLOGI

(dr._____________________)