P3D ANESTESI MINGGU I (IGD/BLUE LINE)

NAMA : TANGGAL/HARI :
NIM : JAM :

STATUS PASIEN ANESTESI

Pasien: Umur/Kelamin:
MR: BB/TB (PBW):
KU:
Telaah:

RPT:
RPO:

Time Sequence:

Primary Survey
A: Airway: Snooring: Gurgling: Crowing: C-Spine:
Lain:
B: RR: x/i SP/ST: SaO2: %
Lain:
C: Akral: (H/D) (M/P) (K/B) TD: / mmHg HR: x/i reg/irreg: T/V: T:
Lain:
D: Sens: GCS: (E /V /M ) Pupil: Ø: mm/ mm RC: /
Lain:
E: Fx:
UOP: Volume: cc Warna:
Lain:
Tindakan:

Hasil:
Secondary Survey
B1: Airway: RR: x/i SP/ST:
Snooring: Gurgling: Crowing: GL: Alergi: Asma: Batuk: Sesak:
Lain:
B2: Akral: (H/D) (M/P) (K/B) TD: / mmHg HR: x/i reg/irreg: T/V: T:
Lain:
B3: Sens: GCS: (E /V /M ) Pupil: Ø: mm/ mm RC: /
Lain:
B4: UOP: Volume: cc Warna:
Lain:
B5: Inspeksi: Mual/Muntah:
Palpasi: Makan/Minum terakhir:
Perkusi: Lain:
Auskultasi:
B6: Oedem:
Lain:
Radiologi:

CT – Scan:

EKG/USG:

Histopatologi:

Laboratorium
Hb/Ht/Leu/Plt: Albumin:
PT/APTT/TT/IN : KGD:
Ur/Cr/UA: Bil. Tot/Direk:
Na/K/Cl: SGOT/SGPT/ALP:
AGDA
pH: SaO2: Total CO2:
PCO2: HCO3: Interpretasi AGDA:
PaO2: BE:
Lain:

Status Dehidrasi
Ringan 3 – 5 % BB Sedang 6 – 8%BB Berat > 10%BB
Turgor Baik ↓ ↓↓
Hemodinamik Takikardia Hipotensi, nadi lemah Tensi TTU/nadi TTB
Rasa haus Haus Sangat haus
Soft tissue Normal Lidah lunak, keriput Mata cowong, sianosis
Urine Normal Pekat Oliguria
Kesadaran Baik Gelisah ↓
Kelas Dehidrasi:
Rehidrasi:

2
Status Perdarahan
Class I Class II Class III Class IV
Blood Loss ≤ 750 750 – 1500 1500 – 2000 ≥ 2000
% blood loss ≤ 15% 15 – 30% 30 40 % ≥ 40%
Pulse Rate < 100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure N or Increased Decreased Decreased Decreased
Respiratory Rate 14 – 20 20 – 30 30 – 35 >35
Urine Output (cc/j) >30 20 – 30 5 – 15 Negligible
Mental Status Slightly anxious Mildly anxious Anxious and Confused and
confused lethargic
Kelas Perdarahan:
Resusitasi Perdarahan:

Monitoring perdarahan dan balans cairan

Jam
Cairan
Kristaloid
Koloid
WB
PRC
FFP
Trombosit
UOP
Perdaraha
n

Permasalahan:

Rencana:

Diketahui oleh,

PPDS STASE IGD/BLUE LINE