RS MUTIARA HATI MOJOKERTO NO.

RM

Ruang : Nama :
Kelas : Jenis Kelamin :
STATUS ANESTESI
Tanggal Lahir :
Alamat :
Diisi oleh Dokter / Perawat : ...........................................................................................................................................................
Diagnosis Pra – Anastesi :……………………………...............……. Spesialis Bedah :…………..............……………………..
: ……………………………...............……
Rencana Tindakan : …………………………………............... Asisten Bedah : ……………………………............….
Tanggal : ………………………………...............… Spesialis Anestesiologi :…………………………...........
Tempat : ……………………………….................. Asisten/Perawat Anestesi :………………………...........
I. ASSESMENT PRA – ANESTESI
Anamnesa dari : Pasien Keluarga Lainnya…….................................. BB : ............ kg
Riwayat anestesi : Tidak Ada Ada, ...................................................................... TB : ............ cm
Komplikasi : Tidak Ada Ada, ...................................................................... Tanda- tanda vital :
Merokok : Tidak Ya, Jumlah ................../ hari TD : .................... mmHg
Alkohol : Tidak Ya N : .................. x/ mnit
Obat – obatan yang sedang dikonsumsi…………………………….................................... RR : .................. x/ mnit
Riwayat alergi : Tidak Ada Ada,....................................................................... S : .................. C
Fungsi Sistem Organ DBN
Pernafasan
Asma PPOK Batuk produktif Bronchitis ISPA PPOK Pnemonia TBC ........................
Evaluasi jalan nafas
Bebas Ya Tidak Leher Pendek Tidak
Obesitas Ya Tidak Gerak Leher Pendek Tidak
Massa Ya Tidak Gigi Palsu Ya Tidak
Sulit Ventilasi Ya Tidak Buka Mulut ....................……..cm
Alat bantu nafas (jika ada)……….........................................................................................................................................
Kardiovaskular
EKG Abnormal Hipertens Angina Gagal Jantung Kongertif Infark Myokard Pacemaker
Penyakit Katub Disritmia Murmur ArteoSclerotic Heart Dis ..........................
Neuro / Muskuloskeletal
Arthritis Kejang Paralisis Kelemahan Otot Penurunan Kesadaran .....................
Back Problems Pingsan Parestesia CVA / Stoke / TIA Nyeri Kepala / ICP
Renal / Endokrin
Diabetes Mellitus Retensi Urine ISK Gagal ginjal / Dialisis Penyakit Thyroid ....................
Hepato / Gastrointestinal
Obstruksi Usus Sirosis Hepatitis Tukak peptik/ulkus Mual/ muntah ....................
Muskuloskeletal
Otot ................................................................ Tulang ...........................................................
Lain- lain
Anemia Immunosupresan Kehamilan Kanker ....................
Dehidrasi Bleeding Tendencies Antikoagulan Hemofilia
Pemeriksaan Laboratorium Pemeriksaan Penunjang
Darah Lengkap ................................................................................. Echocardiagrafi ................................................................................
Fungsi Ginjal ................................................................................ EKG ...............................................................................
Fungsi hati ................................................................................ Foto Radiologi ................................................................................
Serum elektrolit ................................................................................ Evaluasi Faal paru ............................................................................
Faal hemostatis ................................................................................. Lain- lain ................................................................................
Lain- lain ...............................................................................
SIMPULAN ASSESMENT PRA ANESTESI
PS ASA ........................................................................................................................................................................................
........................................................................................................................................................................................
Cardiac Risk Index .....................................................................................................................................................................................
.......................................................................................................................................................................................
Penyulit ......................................................................................................................................................................................
......................................................................................................................................................................................
RENCANA ANESTESI DAN PREMEDIKASI Diperiksa oleh ................................................................
General Anestesi Tanggal ..................................... Jam.......................WIB
TIVA Intubasi Tanda Tangan
Masker LMA Dokter/ perawat
Regional Anestesi
SAB Epidural
CSEA
Premedikasi :
1. ........................................................................ (......................................)
2. ........................................................................
3. ........................................................................
4. ........................................................................

RM 22 b K Rev. 01 / Des/ 2018

II. ASSASMENT PRA – INDUKSI III. DAFTAR TILIK KESELAMATAN PASIEN
Makan Terakhir :………………… Identifikasi Pasien
Minum Terakhir :…………………….
EKG
Vital sign : Ijin Operasi
TD :…………mmHg HR :………..x/menit Sabuk Pengaman
SpO2 :…….. % RR: .............. x/menit
Puasa dijalankan dengan baik
Masalah Saat Induksi : Tidak Ada Suction
Ada, sebutkan..................................................
Mesin Anestesi
Perubahan Rencana Anestesi : Tidak Ada Urine Kateter
Ada, sebutkan.........................................
Obat – Obatan
Tanggal/ jam : .......................................... Titik-titik tekanan diperiksa dan diberi bantalan
Tanda Tangan Perawat/ Dokter
Antibiotik profilaksis
Mata terlindungi
Pulse Oxymeter
(........................................)

IV. INTRA ANESTESI

1.Teknik Anestesi : ................................................................................................................................................................

.................................................................................................................................................................
.................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
General anestesi : Laringoskopi derajat 1 – 4 ................ SAB : Spinocan No ..................................................
LMA no….......Cuff:……...ml ........................................................................
ETT………….Oral / Nasal ........................................................................
No…………Cuff…….ml
.............................................................
NGT Tampon Epidural : Jarum .............................................................
Posisi : Supine Prone Tredelenburg Touhy No ......................................................
Lithotomy Lateral .................. .......................................................................
Lokasi infus : ...............................................................

Keterangan
Nama Obat Anestesi/Dosis/Rute
Paraf 1 Paraf 2

1. .................................................................................................................................................... .....................
H
2. .................................................................................................................................................... .....................
I
3. .................................................................................................................................................... .....................
G
4..................................................................................................................................................... .....................
H
5..................................................................................................................................................... .....................
6..................................................................................................................................................... .....................
A
7..................................................................................................................................................... .....................
L
8..................................................................................................................................................... .....................
E
9..................................................................................................................................................... .....................
R
10..................................................................................................................................................... .....................
T

RM 22 b K Rev. 01 / Des/ 2018

 Catatan : ...........................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................

Mojokerto, .....................................
Dokter Anestesi Perawat Anestesi

(.............................) (............................)

V. MONITORING PASCA ANESTESI

RM 22 b K Rev. 01 / Des/ 2018
Data Masuk . Ruang : Tanggal : Jam : WIB

RENCANA ASUHAN PASCA ANESTESI

1. Posisi ...............................................................................................................................................................................................
2. Oksigen ...........................................................................................................................................................................................
3. Infus ................................................................................................................................................................................................
................................................................................................................................................................................................
4. Makan/ Minum ...............................................................................................................................................................................
.........................................................................................................................................................................................................
5. Observasi : Tensi ................. Nadi .................. RR ............. SPO2 .............. kesadaran .................. produksi urine.....................
6. Terapi : 1................................................................................... 4 ........................................................................................
2 ................................................................................... 5 ............,..........................................................................
3 ................................................................................... 6 .......................................................................................
7. Mobilisasi ....................................................................................................................................................................................
8. Lain- lain ......................................................................................................................................................................................
Tanggal keluar : Jam : WIB Pindah ke: Ruangan R. Intensif Pulang
Dokter Anestesi Perawat yang memindahkan Perawat Penerima

RM 22 b K Rev. 01 / Des/ 2018