Status Intra Anestesi.docx

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Pemerintah Kabupaten Sukabumi Badan Layanan Umum Daerah RSUD PALABUHANRATU KABUPATEN SUKABUMI Jl. A. Yani. No. 02 Telp. (0266) 432081, Fax. (0266) 432082

STATUS INTRA ANESTESI

Nama : ……………………………………………………….… Lk/Pr No RM : Ruang/Kls : …………………………….. Tanggal Lahir : Umur : Tanggal Operasi :

Jam mulai Anestesi : 1

Rencana Anestesi

2

Evaluasi Pra Induksi Jam

FRM.6.7.Hal 1/APRIL 2016

Jam mulai Operasi :

 Dokter Operator  Asisten Operator  Scrub Nurse  Dokter Anestesi  Perawat Anestesi  Diagnosa Medis  Rencana Anestesi  Diagnosa setelah tindakan  Sifat Operasi  TD  HR  RR  SaO2  Suhu  BB Puasa

Cito / Urgent / Elektif mmHg x/menit x/menit  °c Kg Makan terakhir jam : Minum terakhir jam :

3

Premedikasi

4

Induksi

5

Tehnik Anestesi

Masalah sebelum induksi

Ada/Tidak, jika ada, sebutkan …

Perubahan rencana anestesi

Ada/Tidak, jika ada sebutkan ….

 ASA 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. Oksigenasi ± IV Umum Inhalasi

1 2 3 4 5 E Dilakukan di

Regional  Posisi Puncture  Level  Masuk Obat 6

Komplikasi Akut

Penanganan

Oleh 6. 7. 8. 9. 10. menit Drip / Intermitten Semi Closed / Semi Open / Closed NTT/ETT(Kinking/non Kinking) nomor : LMA nomor : Face Mask : Spinal / Epidural / Blok Median / Paramedian Volume

mg

FRM.6.7.Hal 2/APRIL 2016

MONITORING INTRA ANESTESI 02 : N20 : Air: Volatile : Infus : Tranfusi : Saturasi 02 : Suhu :

CATATAN : INTAKE 1. Cairan (Kristaloid/Koloid) a. Pre Operasi : cc b. Intra Operasi : cc c. Post Operasi : cc 2.

Transfusi a. Pre Operasi : b. Intra Operasi : c. Post Operasi :

Diperiksa Oleh :

Hari/Tanggal/Jam :

cc cc cc

OUTPUT 1. Perdarahan : a. Pre Operasi : b. Intra Operasi: c. Post Operasi :

cc cc cc

2. Urine a. Pre Operasi : b. Intra Operasi: c. Post Operasi :

cc cc cc

3.

cc

Lain-lain

:

Dokter Anestesi,

Perawat Anestesi,

______________________ Nama jelas, Tanda tangan

______________________ Nama jelas, Tanda tangan

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