PT UPAYA MUTU PRIMA

RUMAH SAKIT BAKTI KARS

Jl. Epicentrum 45 Jakarta

Asesmen Pra Induksi

Tanggal : __________________________________ Pukul : ____________________________

Kesadaran : __________________ TD : __________ Nadi : ____________________________
RR : __________________ Suhu : _________ SpO2 : ____________________________
EKG : __________________________________ Lain-lain : ___________________________

Asesmen ‫ ם‬Sesuai asesmen pre sedasi/anestesi

‫ ם‬Tidak sesuai asesmen pre sedasi/anestesi

Perencanaan ____________________________________________________________________________
____________________________________________________________________________

Infus Perifer : Tempat dan Ukuran

________________________________________________________________________________________
________________________________________________________________________________________
CVC ___________________________________________________________________________________

Posisi
‫ ם‬Supine ‫ ם‬Prone ‫ ם‬Lain-lain
‫ ם‬Lithotomi O Perlindungan mata
‫ ם‬Lateral O Ka O KI

Premedikasi
‫ ם‬Oral __________________________________________________________________________________
‫ ם‬IM __________________________________________________________________________________
‫ ם‬IV __________________________________________________________________________________

Induksi
‫ ם‬Intravena ____________________________________________________________________________
‫ ם‬Inhalasi ____________________________________________________________________________

Tata laksana jalan nafas

Face mask No : Oro/Nasopharing No :
ETT No : Jenis :
LMA No : Jenis :
Tracheostomi :
Bronchospi fiberoptik : ___________________________________________________________________
Glidescope : ___________________________________________________________________
Lain – lain : ___________________________________________________________________

Intubasi
‫ ם‬Sesudah tidur ‫ ם‬Blind ‫ ם‬Dengan margile
‫ ם‬Oral ‫ ם‬Nasal : Oka OKI ‫ ם‬Cuff
‫ ם‬Tracheostomi ‫ ם‬Level ETT ‫ ם‬Pack
‫ ם‬Sulit ventilasi ______________________________________________________________________
‫ ם‬Sulit intubasi ______________________________________________________________________

Ventilasi
‫ ם‬Spontan ‫ ם‬Ventilasi : TV : RR : PEEP :
‫ ם‬Kontrol ‫ ם‬Lain-lain :

Teknik Regional/Block Perifer

Jenis : ____________________________________________________________________
____________________________________________________________________
Lokasi : ____________________________________________________________________
Jenis jarum / No : ____________________________________________________________________
Kateter : ‫ ם‬Ya ‫ ם‬Tidak ‫ ם‬Fiksasi : _____________ cm
Obat-obatan : ____________________________________________________________________
____________________________________________________________________
Komplikasi : ____________________________________________________________________
____________________________________________________________________
Hasil : ‫ ם‬Total block ‫ ם‬Partial ‫ ם‬Gagal

Dokter Anestesi

(___________________)
Nama dan tanda tangan