RM G6

Nama Pasien : ........................................ No. RM :

Jenis Kelamin : L / P Tgl. Lahir : ....................... / ............ Thn/Bln/Hr

RSU SATITI PRIMA HUSADA
DS. BALESONO - KEC. NGUNUT
KAB. TULUNGAGUNG
TELP. 0355 ( 591637 ), FAX ( 0355 ) 591749 Ruang / Kelas : ........................./ .............. Tgl. Masuk : .................................. Jam : ..............

ASESMEN ANESTESI
Diagnosis Pra Anastesi : Spesialis Bedah :
Rencana Tindakan : Asisten Bedah :
Tanggal / Jam : Spesialis Anestesi :
Tempat : Perawat Anestesi :

Assesmen Pra Anestesi

Anamnesa : Pasien Keluarga Lainnya......... Evaluasi Jalan Nafas

Bebas Ya/Tidak
Riwayat Anestesi : Ada Tidak ada Alat Bantu Nafas (Jika .........................
(Sebutkan jika ada) ................................................................................................. Buka Mulut ....................cm
Komplikasi : Ada Tidak ada Jarak Mentohyold ....................cm
(Sebutkan jika ada) ................................................................................................. Jarak Hyothyroid ....................cm
Obat-obatan yang sedang dikonsumsi : ................................................................................................. Leher Pendek / Tidak
................................................................................................................................................................ Gerak Leher Bebas / Terbatas
Riwayat Alergi : Ada Tidak ada Malampathy ..........................
(Sebutkan jika ada) ................................................................................................. Obesitas Ya/Tidak

BB : ................... TB : .......... SMI : .......... Massa Ya/Tidak

Tanda Vital : TD : ..........mmHg Nadi : .........x/menit T : .......... Gigi Palsu ..........................

RR : ..........x/menit Skor Nyeri : Sulit Ventilasi Ya/Tidak

Fungsi Sistem Organ DBN Catatan

Pemeriksaan Laboratorium
Pernafasan
Merokok Tidak Hb/Hct/CBC
Asthma Batuk Produktif Ya .......................................................................
Bronkhitis ISPA Jumlah : ............................/Hari .......................................................................
PPOK Tuberkulosis Selama : .................................... .......................................................................
Dyspnea Effusi Pleura
Fungsi Ginjal
Orthopnea Pneumonia
.......................................................................
Kardlovaskuler Alkohol : Tidak Fungsi Hati
EKG abnormal Hipertensi Ya
.......................................................................
Angina Infark Miokard Selama : ....................................
Serum Elektrolit
Artero Skletoris Heart Disease Murmur .......................................................................
Gagal Jantung Kongestif Pace Maker Faal Hemostasis
Disritmia Demam Rheumatik ......................................................................
Limitasi Aktifitas Penyakit Katup
Lain-lain
Neuro Muskuluskeletal ......................................................................

Arthritis Kelembaban Otot ......................................................................

Back Problems Neuron Muscular Disease Pemeriksaan Penunjang

CVA/Stroke/TIA Paralisis Echocardiografi

Nyeri Kepala/ICP Parastesia ......................................................................

Penurunan Kesadaran Pingsan ......................................................................
Kejang ECG

Renal / Endokrin ......................................................................

......................................................................
Diabetes Melitus Retensi Urine
......................................................................
Gagal Ginjal / Dialisis ISK
Penyakit Thyroid Berat Badan Turun ......................................................................
......................................................................
Hepato / Gastrointestinal
Lain-lain
Obstruksi Usus Refluk
......................................................................
Sirosis Mual dan Muntah
Hepatitis / Icterus Tukak / Ulkus Peptik

Lain-lain SIMPULAN EVALUASI PRA-ANESTESI

PS ASA : ...................................................................................
Anemia Imunosupresan
PENYULIT : ...................................................................................
Bledding Tendencies Kehamilan
...................................................................................
Kanker Sickle Cell Dis / Trait
...................................................................................
Dehidrasi Riwayatt Transfusi
KOMPLIKASI : ...................................................................................
Hemofilia Antikoagulan
...................................................................................
RM G6/ANESTESI/RSU.SPH/I/2019.Rev Hal 1 dari 5
 RM G6

Nama Pasien : ........................................ No. RM :

Jenis Kelamin : L / P Tgl. Lahir : ....................... / ............ Thn/Bln/Hr

RSU SATITI PRIMA HUSADA
DS. BALESONO - KEC. NGUNUT
KAB. TULUNGAGUNG
TELP. 0355 ( 591637 ), FAX ( 0355 ) 591749 Ruang / Kelas : ........................./ .............. Tgl. Masuk : .................................. Jam : ..............

LAPORAN ANESTESI
ASESMEN ANESTESI / SEDASI
AHLI ANESTESIOLOGI : PERAWAT : DARI RUANG AHLI BEDAH :
RESIDEN :

DIAGNOSA PRA BEDAH : JENIS PEMBEDAHAN : LAMA OPERASI :

DIAGNOSA PASCA BEDAH JENIS : JENIS ANESTESI : LAMA ANESTESI :

KEADAAN PRA BEDAH : ................. TB : ............Cm BB : ..........KG ANESTESI DENGAN :

GOL. DARAH : .......... TERAKHIR MAKAN : ............. MINUM : ..............
O
TENSI : ............mmHg NADI : ............X/mnt SUHU : ..........C
PERNAFASAN/JALAN NAFAS: RELAKSASI DENGAN :
AIRWAY : PATEN/OBSTRUKSI RR : .............x/MENIT GIGI : .................
BUKA MULUT : .........cm MALAMPATTI : ..........GERAK LEHER : FLEXY/EKSTENSI
JARAK MENTOTHYROID : .................CM
TEKNIK ANESTESI :
SUARA NAFAS : 1. VESICULAR
2. RONCHI : ........./ ......
3. WHEEZING :......../ .......
RIWAYAT ASMA/ALERGI : ............/ .......
CARDIOLOGI : EKG .............................. X-RAY THORAX .......................................
PULMONOLOGI : ................................... ECHO ........................................................
SIRKULASI : CYANOSIS : ................................. TEKNIK KHUSUS :
PERFUSI : .......................................... CRT : ..................................
SARAF : PERNAFASAN :
- GSC : ..............................
- AVPU : .............................. POSISI :
- LATERALISASI : .............................
GASTROINTESTINAL : INFUS :

PENYULIT SELAMA PEMBEDAHAN :

GINJAL : KEADAAN AKHIR PEMBEDAHAN :

METABOLIK : KEADAAN BAYI SAAT SEKSIO

CAESARIA :
AS 1 menit
AS 5 menit
HATI : TINDAKAN KHUSUS PASCA BEDAH :

PENYULIT PASCA BEDAH :

MADIKA PRA BEDAH : HIPERSENSITIVITAS/ALERGI :

MASALAH ANESTESI : MASALAH BEDAH : KEMATIAN :

SIRKULASI PARU HATI GINJAL SSP DARAH NUTRISI LAIN-LAIN

RENCANA:
1. Anestesi Umum : A. Intubasi Endotracheal Tube B. Face Mask (FM)
ASA : 1,2,3,4,5,E C. Laringeal Mask Airway (LMA) D. Total Intravena Anestesia (TIVA)
1. ELEKTIF 2. Anestesi Regional : A. Sub Arachnoid Block (SAB) B. Combine Subarachnoid-Epidural (CSE)
2. EMERGENCY C. Epidural Block (EB) D. Block Gangglion / Saaraf Perifer
3. Lain - lain
RM G6/ANESTESI/RSU.SPH/I/2019.Rev Hal 2 dari 5
 RM G6
PREMEDIKASI
Nama Obat & Dosis Pemberian Cara Pemberian Waktu Pemberian Reaksi
1.
2.
3.
4.
5.
ASESMEN INTRA ANESTESI
Pra induksi
KU : ....................... Kesadaran : ................. Pernafasan / Jalan Nafas : .................................
Tensi : .......................mmHg Nadi : .................X/mnt Perfusi : ............................. Suhu : ...................
Urine : .......................cc LAIN-LAIN
Induksi
Medikasi
1. 6. 11. 16.
2. 7. 12. 17.
3. 8. 13. 18.
4. 9. 14. 19.
5. 10. 15. 20.

O2
N2O
Agen inhalasi :
Infus
Induksi
Depol Relawan

Analgenik
Neuroleptik
Lain-lain

R N TD
• - N -• 0 - R - 0 • V Sist•^ Diast

26 220
C.R = Contr. Resp. | Intubasi | Esktubasi

24 200
S.R = Spont. Resp. AR = Ass. Resp

- Operasi -

20 180
16 180 160
12 160 140
140 120
120 100
100 80
X - Ana - X

80 60
60 40
20

Respirasi :
Stadium Ops

I Jumlah Cairan/Transfusi Cairan Keluar Catatan

II

III

IV

Perdarahan : Petugas Anestesi :

( )
RM G6/ANESTESI/RSU.SPH/I/2019.Rev Hal 3 dari 5
 RM G6
PASCA ANESTESI
Masuk Jam : ...................
Keadaan umum : Belum sadar / sadar / refleks (-) / refleks (+) / panas / syok / lain-lain .......................................
Pernapasan : baik / sesak pada pipa endotraheal / pernapasan dibantu / pernapasan kontrol / lain-lain
Tekanan darah : .........................mmHg Nadi : ............................... / menit Suhu badan : ........................oC
S R N TD WAKTU
- - - 240

41 36 - 220
40 32 - 200
39 28 - 180
38 24 - 160
37 20 180 140

36 16 160 120

35 12 140 100

34 8 120 80

33 - 100 60

32 - 80 40

31 - 60 20

30 - 40 0

29 -
28 -
Infus
Urine
Muntah
ALDRETTE SCORE
KESADARAN : sadar penuh 2 PERGERAKAN : gerak terkendali 2
: tak sadar, ada reaksi terhadap rangsangan 1 : gerak tak terkendali 1
: tak ada reaksi terhadap rangsangan 0 : tak bergerak 0
PERNAPASAN : teratur kuat batuk 2 WARNA KULIT : merah 2
: napas berat depresi 1 : pucat 1
: napas dibantu 0 : sianosis 0

TENSI : sama dengan nilai awal + 20% 2

: berbeda 20 - 30 % dari nilai awal 1
: berbeda lebih dari 30 % dari nilai awal 0
Keterangan : pasien pindah ke ruangan rawat inap jika total score > 8, Jika pindah ICU tanpa menilai aldrette score

BROMAGE SCORE
Jika terdapat gerakan penuh tungkai 3
Jika mampu memfleksikan lutut tetapi tidak bisa mengangkat tungkai 2
Jika tidak mampu memfleksikan lutut 1
Jika tidak mampu memfleksikan pergelangan kaki 0
Keterangan : pasien pindah ke ruangan rawat inap jika total score > 2
SCALA NYERI

0 1 2 3 4 5 6 7 8 9 10
Tidak Nyeri Nyeri Nyeri Nyeri Berat Nyeri Berat tak
Ringan Sedang Terkontrol Terkontrol
Discharge Summary :
1. Total Nilai Aldrette Score : ........................ 4. Rekomendasi : 1. Kembali ke ruangan ...........
(Bila pasien pasca anestesi umum) : ........................ 2. Pindah ke ICU
2. Total Nilai Bromage Score : ........................ 3. Pindah ke PICU / NICU
(Bila pasien pasca anestesi regional) : ........................ 4. Pulang
3. Skala Nyeri 5. Lain-lain : .......................
Keluar Jam : ............
Petugas Recovery Room (RR)
(..............................................)
RM G6/ANESTESI/RSU.SPH/I/2019/Rev Hal 4 dari 5
 RM G6
INSTRUKSI PASCA ANESTESI
Monitor :
Nafas : .......... Tensi : .......... Nadi : .......... Suhu : .......... Setiap : .......... Selama : ..........
Infus : ................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Antibiotik : ................................................................................................................
................................................................................................................
................................................................................................................
Obat-obatan lain : ................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Bila mual/muntah : ................................................................................................................
................................................................................................................
................................................................................................................
Bila kesakitan (Skala Nyeri > 3) : ................................................................................................................
Minum / Makan : ................................................................................................................
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Lain-lain : ................................................................................................................
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TTD Ahli Anestesiologi

(dr. ...........................................)
RM G6/ANESTESI/RSU.SPH/I/2019.Rev Hal 5 dari 5