RM. 12.

Nama Pasien : No. RM :

STATUS ANESTESI Tanggal Lahir : Jenis Kelamin : L / P
Umur : Ruangan :

Hal. 1 dari 2
Tanggal Operasi : Spesialis Bedah : Spesialis Anestesi : Diagnosis Pra Anestesi : Catatan :
Diagnosis Pra Bedah : PPDS Bedah : PPDS Anestesi : PS ASA 1 2 3 4 5 6 E
Rencana Pembedahan : Perawat Bedah : Perawat Anestesi : Rencana Anestesi :
I. EVALUASI PRA INDUKSI III. INDUKSI
Makan terakhir : Tanda vital Premedikasi Teknik Intubasi : ...................................................................................................... Teknik Induksi : ....................................................................................................
Minum terakhir : TD : mmHg RR : x / menit Agen 1 .................................................................................................................................. ...............................................................................................................................
o
N : x / menit T : .................... C 2 .................................................................................................................................. ...............................................................................................................................
Masalah saat induksi : Ada Tidak Ada SpO2 : Skor Nyeri 3 .................................................................................................................................. ...............................................................................................................................
Sebutkan jika ada : ........................................................................................................... Perubhan Rencana Anestesi : Ada Tidak Ada 4 Posisi Supine Lithotorny Airway
................................................................................................................................................... Sebutkan jika ada : .................................................................................................................................................. Prone Lateral Laringoskopi derajat 1-4 ETT............. Oral/Nasal
................................................................................................................................................... ........................................................................................................................................................ Diberikan oleh : ........................................................
Tredelenburg Lainnya ........................................... LMA No..... Cuff: ......ml No............... Cuff
Tanggal / jam : ........................................................ NGT Tampon
Lokasi Infus/Tipe kanula
1. ................................ Tempat CVC : .........................
2. ................................. Tempat Arterial / Tipe kanula : ........................................................
Tanda Tangan Dokter Tanda Tangan Perawat / Dokter Kateter Arteri Pulmonal : ........................................................................
II. DAFTAR TILIK KESELAMATAN PASIEN
Identifikasi Pasien Puasa dijalankan dengan baik Suction Antibiotik proflaksis EKG Urin Kateter Termometer Urin Kateter Pasca Induksi
Ijin Operasi Mesin Anestesi Obat-obatan Pulse Oxymeter Sabuk pengaman Penghangat Cairan Selimut Penghangat Penghangat Cairan Mata terlindungi Titik-titik tekanan diperiksa dan diberi bantalan
IV. MONITORING INTRS ANESTESI
Obat-obatan
1............................... Keterangan
2...............................
Pernafasan
3...............................
4............................... RR TD Nado
5............................... 40 220
6...............................
Sistolik
7............................... 35 200
8...............................
Diestolik
9............................... 30 180
10... ...........................
X Mulai Operasi
11. ............................ 25 160
12.............................
0 Mulai Anestesi
VENTILASI 20 140
Circuit
Spontan 15 120
TANGGAL :
Assited/SIMV
CMV 10 100 Jam Masuk :
PCV OK
TV : 80
Jam Induksi :
Rate :
PEEP : 60
Jam Inisisi :
Gas Flow
N2O Lpm 40
Tanggal :
O2 Lpm
Air 20 Jam Selesai :
Gas Inhalasi Operasi
1. ........................... 10
Jam Selesai :
2. ........................... Anestesi
3. ........................... 0 Jam Keluar :
Sp0 OK
ETCO Bayi Lahir :
CVP/ScO2 Jam
MAP Apgar Score :
RIS BB :
Temp
Input TB :

Output
Cairan Pra-Anestesi Cairan Intra Anestesi
Cairan Masuk 1............................... Cairan Keluar Cairan Masuk Cairan Keluar
Kristaloid 2............................... Urin : ....................................... Kristaloid 1............................... Urin : .........................................
3............................... S&I : ....................................... 2............................... S&I : .........................................
Kolloid 1............................... Darah : ....................................... 3............................... Darah : .........................................
2............................... EBV : ....................................... Kolloid 1............................... EBV : .........................................
3............................... 2...............................
Darah : WB............................. 3...............................
FFP............................. Darah : WB.............................
RRC............................ FFP.............................
TC.............................. RRC............................
TC..............................
Lain - lain : ............................................. Lain - lain : .............................................

ANESTESI REGIONAL / BLOK SARAF PERIFER Perubahan / Penambahan Tindakan Anestesi Intra Operasi Catatan
Teknik : Spiral Obat Anestesi lokal : ..................... Volume, ......ml, Konsebtrasi ........ % Ada Tidak Ada
Lokasi Insersi Jarum Spiral : Interspace lumbal........................
Level tinggi Blok Sprial : ........................... Sebutkan jika ada ................................................................................................................................................................
Epidural Obat Anestesi lokal : ................ Volume, ......ml, Konsebtrasi ........ % ...........................................................................................................................................................................................
Lokasi Insersi Jarum Epidural : ........................ .............................................................................................................................................................................................
Panjang kateter dalam ruang Epidural : ................... cm Banjarmasin, ...................................
Level tinggi Blok Epidural : ...........................
Caudal Obat Anestesi lokal : ................ Volume, ......ml, Konsebtrasi ........ %
Level tinggi Blok Caudal : ...........................
Blok Saraf Perifer : ............................ Guiding : USG Nerve Stimulator
Obat Anestesi lokal : ................ Volume, ......ml, Konsebtrasi ........ %
Masalah / Keterangan :

Tanda Tangan Dokter

REV. I / RM 12.4 a - RM 12. 6 - RM 12.7 - RM 12.8 - 2018 / 08 / 06 - ANESTESI