Assesmen Pra Anestesi: Kesadaran

RM.
35d
RUMAH SAKIT MITRA SEHAT MANDIRI RM :

SIDOARJO Nama :......................................L/P
Jl. Raya Krian – Mojosari KM.03, Tropodo, Krian, Tgl. Lahir/Umur :.............................../.......Th
Sidoarjo Kodepos : 61262Telp / Fax : 031 – 99891626
e-mail : rumkit.msms@gmail.com Alamat :............................................
(Mohon diisi atau di tempel Stiker Label jika ada)
ASSESMEN PRA ANESTESI

Berat Tekanan Frekuensi Frekuensi Sp.0 Diagnosa :
Kesadaran Suhu
Badan Darah Nadi Nafas 2
Riwayat Operasi / Anesti Ada Tidak Ada Rencana Tindakan :

Riwayat komplikasi Anestesi pada pasien/keluarga Ada Tidak Ada
Gigi: Tampak normal Goyah Obat yang sedang dikonsumsi
Gigi palsu Semua Sebagian Atas Bawah
Gigi ompong Semua Sebagian Atas Bawah Alergi Obat/Makanan :
Jalan Nafas : Tidak ada masalah yang terlihat
Skor Mallampati : Pemeriksaan Lan PA
Tonsil
Rontgen :
T1 T2 T3
USG :
B1 Airway Breathing
EKG :
Asma TBC Pernafasan
PPOK Pnurmonia Spontan CT SCAN :
ISPA Pneumo/Henatothorax Intubasi
Sleep Tracheostomy
Hb : ................. Ht : .................Hbs Ag : .................
Apnea Normal
Leukosit : ................................. Anti HIV: ...............
Merokok......................Batang/bungkus
Trombosit: .............................. NA: ........................
Lain-lain......................
GDS : ....................................... K : ..........................
BUN/SC : ................................. Cl : .........................
B2 Kardiovaskular
SGOT : ..................................... Ca : ........................
Agina Pacemaker Normal
PJK Penyakit Katub Lain-lain Puasa
CHF Cardimegali / Makan Terakhir Pukul
Aritmia Cardiomiopati Minum Terakhir Pukul
Hipertensi
Rencana Anestesi :
B3 Neuro / Sistem Persyarafan ASA 1 2 3 4 Elektif/Cyto
Trauma Capitis Kejang Normal
CVA / TIA Polio Lain-lain Rencana GA – REG – IV Sed – LA – PNB
Kelumpuhan Tumor
Penyakit Neuromuskular Premedikasi :
Obat Waktu
B4 Urinari Track / Saluran Kemih ...............................................................................
Batu ISK Normal
BPH CKD Lain- lain ...............................................................................
Hematuria Trauma
...............................................................................
B5 Sistem Pencernaan
Hepatitis Pendarahan/Trauma Gastritis Normal ...............................................................................
Tumor Ulcus pepticum Ileus Lain-lain
cholelitiatis Infeksi ( Peritonotis/Appendicitis Sidoarjo,............................ Jam : ...........
B6 Musculoskeletal
Fraktur (open/close) ` ISK Normal
Dislokasi CKD Lain- lain
Osteomyelitis Trauma
(..............................................)
Abnormalitas postur: Scoliosis Lordosis Kyphosis Nama Terang & Ttd
Lain-lain
FORM/13/F/RM.13D
RM.35d
Endoktrin DM ` Obesitas Hypothyroid Hiperthyroid
Kagulopati Kehamilan Riwayat Psikiatri
Abnormalis Darah Leukimia ITP Feal Hemositas
Berilah tanda (√) pada tanda yang sesuai

SIDOARJO
Jl. Raya Krian – Mojosari KM.03, Tropodo, Krian, Nama :......................................L/P
Sidoarjo Kodepos : 61262Telp / Fax : 031 – 99891626 Tgl. Lahir/Umur :.............................../.......Th
Dokter
Tanggal : :
............................................... Anestesiologi ...............................................
Diagnosa Pra Bedah : ............................................... Dokter Bedah : ...............................................
Rencana Operasi : ...............................................
ASESMEN PRA INDUKSI/SEDASI

1. Pemeriksaan Fisik
Kesadaran : ...................... Suhu Tubuh : ...................... Pemeriksaan : ......................
RR : ...................... Skala Nyeri : ...................... Gigi Palsu : ......................
SpO2 : ...................... Makan Terakhir : ...................... IV Kanula : ......................
TD : ...................... Minum Terakhir : ......................
HR : ...................... BB/TB : ......................
2. Data Penunjang
HB : ...................... Foto Rontgen : Ada / Tidak Informed concern
Lekosit : ...................... Ct-scan : Ada / Tidak Rencana Tindakan Anestesi
Trombosit : ...................... USG : Ada / Tidak Ada / Tidak
TDPT/APT : ...................... Persiapan Darah : Ada / Tidak
HbsAg : ...................... Jenis..................
Ureum/creatinin : ...................... Gol....................
GDA :
...................... Jumlah..............
3. Masalah Pra Induksi : Ada / Tidak
Sebutkan jika ada

..................................................................................................................................
..................................................................................................................................
4. Perubahan Rencana Anestesi : Ada / Tidak
Sebutkan jika ada

..................................................................................................................................
..................................................................................................................................
FORM/13/F/RM.13D
RM.35d
5. Pre Medikasi
No Obat / Dosis Waktu pemberian Lokasi Pemberian Pelaksanaan
Hasil Premedikasi :
..................................................................................................................................
..................................................................................................................................
Sidoarjo,...................................
Dokter Anestesesiologi
(.........................................................)
Nama Jelas & TTD
SIDOARJO
LAPORAN ANESTESI
Dr. Anestesiologi Jenis Tindakan Operasi : Jenis Anestesi :
Dr. Bedah GA RA PNB
Diagnosis Pra Anestesi : Diagnosis Pasca Anetesi : Posisi Operasi Posisi Anestesi
` Supine Litotomy Duduk Median Tinggi
Prone Lateral D/S Miring Blok Paramedian
Pernafasan : SR AR CR
Keadaan Pra Anstesi :
Teknik Anestesi :
TB : ................. cm BB : ................. cm Gol Darah : .......... GA : Masker TIVA LMA No...... INTUBASI ETT.....(N/K)
RA : SAB Spinocan............ Peridual Tuhoi.................
Terakhir Makan/ Minum : ....................................... PNB :
Masalah SAB .Darah-/+.Tinggi Blok ..................
Pernafasan : RR ......X/menit SpO2: .......
Anestesi
Sirkulasi :T N: Perfusi : t : ˚c Lama Operasi : Lama Anestesi
................s/d.............. ................s/d..............
Syaraf : AVPU / GCS :
Pra Operasi Durante Operasi
Gastro Intestinal Distendet Soepel Cairan Masuk : Cairan Masuk :
Ginjal Spontan Kateter Kristalloid : Kristalloid :
Hepatitis HIV Koloid : Koloid :
Metabolik / Endokrim : Darah : Darah :
Cairan Keluar : Cairan Keluar :
Medikasi Pra Anestesi : ......................................................... Urine : Urine :
NGT : NGT :
Darah : Darah :
........................................................
. Keadaan Bayi Pada Sectio Caesarea
Status Fisik : ASA : 1 2 3 4 T/D

PREMIDIKASI : Induksi Bayi II Bayi II Bayi III
Pemberian : SK/LM/I.V/P.Oral 1. Jam Lahir .................... .................... ....................
Waktu : Jam............... 2. AS 1 menit .................... .................... ....................
Efek : ..................... 3. AS 5 menit .................... .................... ....................
4. Jenis Kelamin .................... .................... ....................
Medikasi Pra Induksi Relaksasi dengan Berat Badan .................... .................... ....................
Panjang .................... .................... ....................
FORM/13/F/RM.13D
RM.35d
Pendarahan : Keadaan Akhir Tindakan : TD :........ mmHg N: ........x/mnt RR :......... x/mnt Perfusi :.....
Sebab kematian :`
Catatan : Sidoarjo.............................................. Jam :...............
Dokter Anestesiologi Perawat Anestesi
(...........................................) (...........................................)
Nama jelas & Ttd Nama jelas & Ttd

SIDOARJO Nama :......................................L/P
Jl. Raya Krian – Mojosari KM.03, Tropodo, Krian,
MONITORING PASCA ANESTESI

Diagnosa Pasca Anestesi Monitoring oleh Jenis Anestesi
TD
Temp
N
41˚ 220
40˚ 200
39˚ 180
38˚ 160
37˚ 140
36˚ 120
35˚ 100
34˚ 80
33˚ 60
32˚ 40
31˚ 20
30˚ 10
29˚ 5
RR
SP.O2
INFUS
FORM/13/F/RM.13D
RM.35d
DRAIN
NGT
URINE
EVALUASI NYERI PASCA ANESTESI
Skor nyeri Pra anestesi Nilai Jam 0’ 5’ 15’ 30’ 45’ 1 2 3 4 Keluar
Nyeri : +/-
Metode penilaian nyeri 1-10
VAS/NRS
SKOR BROMAGE PASCA ANESTESI

SKOR BROMAGE PASCA ANESTESI : Nilai Jam 0’ 5’ 15’ 30’ 45’ 1 2 3 4 Keluar
 Gerakan penuh dari tungkai 0
 Tak mampu eskstensi tungkai 1
 Tak mampu fleksi lutut 2
 Tak mampu fleksi pergelangan tangan 3
SKOR ALDRETE PASCA ANESTESI
TD-Anestesi : Nilai Jam 0’ 5’ 15’ 30’ 45’ 1 2 3 4 Keluar
TD +/- mmHg dari normal 2
Sirkulasi TD +/- 20-50 mmHg dari normal 1
TD +/- 50 mmHg dari normal 0
Sadar Penuh 2
Kesadaran Respon Terhadap Panggilan 1
Tidak ada respon 0
SpO2 > 92 % ( dengan udara bebas ) 2
Oksigenasi SpO2 > 90 % ( dengan suplemen O ) 1
SpO2 < 90 % ( dengan suplemen O ) 0
Bisa menarik nafas dalam dan batuk bebas 2
Pernafasan Dispneu atau limitasi bernafas 1
Apnea / tidak bernafas 0
Mengerakan 4 ektremitas 2
Aktivitas Menggerakkan 24 ekstremitas 1
Tidak mampu menggerakkan ekstremitas 0
Waktu Pesanan / tindakan di Ruang Pulih Sadar TT. Perawat TT. Dokter
FORM/13/F/RM.13D
RM.35d
Pasien Pindah Ke : ... Tanggal / Jam : ... Disetujui oleh : ...
Diagnosis Pasca Anestesi :

1. Infus
2. Puasa Sampai dengan
Minum Jam : Makan : Jam :
Bila
3. Observasi
Tensi : ... Nadi :... Kesadaran :.... Produksi Urine : ...
Perfusi : ...
4. Terapi
1. ......................................................................... 6. .........................................................................
2. ......................................................................... 7. .........................................................................
3. ......................................................................... 8. .........................................................................
4. ......................................................................... 9. .........................................................................
5. ......................................................................... 10. .......................................................................
5. Lain- lain
Dokter Anestesi Perawat RR
(...........................................) (...........................................)
TTD & Nama Terang TTD & Nama Terang

SIDOARJO
FORM/13/F/RM.13D
RM.35d
TRANSFER PASIEN
Tanggal Pindah : .....................................Jam ............... Pindah ke Ruang : .................................Kelas................
DPJP : ........................................................... Dokter Konsulen : .........................................................
Diagnosis Masuk : ........................................................... Diagnosis Sekarang : .........................................................
Indikasi Pasien Masuk Dirawat : ...................................................................................................................................................
1. Pemeriksaan Fisik
 Keadaan Pasien Saat Dipindah..............................................................................................................................................
 Kesadaran : ............................................................................................................................................................
 Pemeriksaan Tanda-tanda Vital : Tensi : Mmhg Suhu : ˚c Nadi : X/mnt
 Keluhan : ...............................................................................................................................................................
 Riwayat Kesehatan : ...............................................................................................................................................................
2. Pemeriksaan Diagnostik yang sudah di lakukan
 Laboratorium : .........................................................................................................................................................................
..................................................................................................................................................................................................
 EKG  Foto Abdomen  CT Scan : ......................................
 Thoraks Foto : .........................  Spirometri  CTG : ......................................
 Foto Cervikal  Echo / Treadmill 
 Foto Genu/Ferum  USG 
3. Alat yang dipasang pada pasien
...............................................................................................................................................................................................
4.Tindakan Medis yang sudah di lakukan
...............................................................................................................................................................................................
...............................................................................................................................................................................................
...............................................................................................................................................................................................
5.Pemberian Obat Saat Dirawat

 Infus : ................................................................................................................................................................................
.....................................................................................................................................................................................
 Obat Injeksic
1. .......................................................................... 4. ..........................................................................
2. .......................................................................... 5. ..........................................................................
3. .......................................................................... 6. ..........................................................................
 Obat Oral
1. .......................................................................... 4. ..........................................................................
2. .......................................................................... 5. ..........................................................................
3. .......................................................................... 6. ..........................................................................
FORM/13/F/RM.13D
RM.35d
 Lain-lainnya : .........................................................................................................................................................................
...............................................................................................................................................................................................
Petugas Pengirim Petugas Menerima
(........................................) (........................................)
FORM/13/F/RM.13D

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