DEPARTEMEN ILMU ANESTESI, PERAWATAN INTENSIF DAN MANAJEMEN NYERI

FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN

RENCANA OPERASI ELEKTIF INSTALASI BEDAH PUSAT

RSUP Dr. WAHIDIN SUDIROHUSODO
SENIN, 27 SEPTEMBER 2021

RENCANA POST OP
BB TB RENCANA MABL KONSULEN RSDN RENCANA KONSULEN
NO NAMA PASIEN JK NO. RM UMUR (Th) BMI Tanggal Masuk DIAGNOSA JAM BAGIAN MASALAH PERIOPERATIF ASA PS
(KG) (CM) TINDAKAN (CC) BEDAH ANST ANESTESI PAIN MANAGEMENT PERAWATAN ANESTESI

AKTUAL:
- Penurunan suara napas hemithorax (D)
setinggi ICS VIII Rh -/-, Wh -/-.
terpasang chestube pda hemithoraks (D),
produksi (-), undulasi (+)
- Breath holding test: 26 detik
- Frankle score A
- Anemia (Hb : 10 gr/dL)
- Leukositosis (WBC 14.300/mm3)
- Foto thorax (6/9/2022): Terpasang
chest tube pada hemithoraks (D), efusi
pleura (D) kesan perbaikan, destruksi 2,
CV Th.IV Preanestesi/Pra
Fentanyl 30
- MSCT thoracal (25/8/2022): Burst bedah Dr. Madonna
GETA ETT Non mcg/jam/SP/IV (untuk
7 September 2022 Destruksi CV Thoracal Dekompresi Dan Dr. Andi fraktur CV thorakal IV disertai destruksi Screening D. Datu,
1 Martinus L 985858 60 50 160 19.53125 625 08:00 B. Saraf RZR Kinking ID 7.0 1x24 jam) + Ketorolac 30 ICU
(Poli) IV + Paraplegia Stabilisasi Posterior Ihwan, Sp.BS end plate posteroinferior CV thorakal III, Covid-19: Sp.An, KMN-
mm Posisi Prone mg/8 jam/IV ( selama
nodul thyroid (S) Uk. 1,8x1,8x2,5 cm Resiko Rendah FIPM
3x24 jam)
- Swab nasofaring (7/9/2022) : Negatif Covid-19 (Skor
POTENSIAL: <3)
- Laryngospasme
- Bronkospasme
- Dislokasi ETT
- Hipoksia
- Hipotensi
- Bradikardi
- Aritmia
- Cardiac arrest
- Cedera nervus perifer
- Post operasi vision loss
- Iskemik organ genitalia

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
12 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
13 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

AKTUAL:
-
PEMERIKSAAN PENUNJANG:
2,
- MSCT whole abdomen: Abses
Preanestesi/Pra
perirenal dextra. Severe
bedah
hydronephroureter bilateral et causa
Screening Metamizole 1 gr/8 jam/IV Dr. Rusmin B
14 #DIV/0! 0.0 multiple uretrolith bilateral. GA TIVA L1AB
Covid-19: (selama 3x24 jam) Syukur, Sp.An
Hepatomegaly disertai kista segmen VIII
Resiko Rendah
lobus dextra hepar. Kalsifikasi spleen.
Covid-19 (Skor
Lymphadenopathy regio superficial
<3)
inguinal bilateral. Reverse
spondylolisthesis CV S5-coccygeus I
POTENSIAL:

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
15 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
16 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
17 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
18 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
19 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)
 ,
Preanestesi/Pra
bedah
AKTUAL:
Screening
20 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
21 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
22 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
23 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
24 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
25 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
26 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
27 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
28 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

,
Preanestesi/Pra
bedah
AKTUAL:
Screening
29 #DIV/0! #DIV/0! -
Covid-19:
POTENSIAL:
Resiko Rendah
Covid-19 (Skor
<3)

30