Form KPA
6
RSUP FATMAWATI KEPANITRAAN KLINIK FK UIN SYARIF HIDAYATULLAH JAKARTA NOMOR RM : _________________________ NAMA : _________________________ UMUR : _________________________ JENIS KELAMIN : P/L DPJP : _________________________ KUNJUNGAN PRA ANESTESI Tanggal: Ruangan: Pemeriksa: ............................................. ANAMNESIS KELUHAN UTAMA: ............................................................. .................................................................... .................................................................... .................................................................... ........................................................... RIWAYAT PENYAKIT SEKARANG: .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................................... .................... .................................................................... .................................................................... .................................................................... .................................................................... .................................................... RIWAYAT PENYAKIT YANG SEDANG/ PERNAH DIDERITA: Alergi: ............... ......... Asma Diabetes Melitus Hipertensi Infeksi saluran nafas atas:.................. ........ Stroke Obesitas Pemebekuan darah Penyakit paru : ................... ........................... Penyakit jantung : ...................... ......................... Penyakit hati : .................. ............................. Penyakit ginjal : ................... ............................
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Transcript of Form KPA
RSUP FATMAWATIKEPANITRAAN KLINIK
FK UIN SYARIF HIDAYATULLAH JAKARTA
NOMOR RM : _________________________NAMA : _________________________UMUR : _________________________JENIS KELAMIN : P/LDPJP : _________________________KUNJUNGAN PRA ANESTESI
Tanggal: Ruangan: Pemeriksa: .............................................ANAMNESISKELUHAN UTAMA: ....................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT SEKARANG:................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT YANG SEDANG/ PERNAH DIDERITA:
Alergi: ........................ Asma Diabetes Melitus Hipertensi Infeksi saluran nafas
atas:.......................... Stroke Obesitas Pemebekuan darah
Penyakit paru : ..............................................
Penyakit jantung : ...............................................
Penyakit hati : ...............................................
Penyakit ginjal : ...............................................
RIWAYAT OBAT-OBATAN: Alergi obat:............................................................................................................................... Obat yang sedang di
konsumsi: ............................................................................................... ..................................................................................................................................................
RIWAYAT ANESTESI:Riwayat Oprasi sebelumnya
Pernah / tidak pernah Tanggal:....................................................................................................................................... Jenis pembedahan:...................................................................................................................... Jenis anestesi: GA/RA/Lokal Komplikasi:...................................................................................................................................
.....................................................................................................................................................RIWAYAT PENYAKIT KELUARGA:
Alergi: ........................ Asma Diabetes Melitus Hipertensi Pemebekuan darah
Penyakit paru : ..............................................
Penyakit jantung : ...............................................
RIWAYAT KEBIASAAN/SOSIAL (yg mempengaruhi tindakan anestesi): Merokok Minum Alkohol
Narkotika Obat obatan penenang
PEMERIKSAAN FISIKTANDA VITAL:
Kesadaran :....................................... Kesan umum :........................................ BB :....................................kg
TD :........................................mmHg Suhu :........................................°C Nadi :.................................kali/menit
TB :....................................cm RR :..................................kali/menitEVALUASI KESULIATAN INTUBASIPemeriksaan Leher dan kepala:
Trismus : Keadaan gigi mulut: Gangguan motorik N. V Spasme otot pengunyah Kesulitan membuka mulut
Hilangnya gigi Gigi palsu Maksila/ gigi maju Micronagtia Madibula menonjol Gerak TMJ terbatas
Leher: 3-3-2 Rules Gangguan mobilitas leher Trauma tulang belakang Leher pendek
Membuka mulut 3 jari 3 jari Jarak submental mandibula 2 jari jarak krikoid tiroid
Masa/ tumor Perbesaran KGB Deviasi trakea
KESIMPULANKemungkinan sulitan intubasi: YA/TIDAK ............................................................................................
Mallapati score
Pemeriksaan Jantung: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan paru: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan abdomen: Inspeksi : ................................................................................................................................. Palpasi : ................................................................................................................................. Perkusi : ................................................................................................................................. Auskultasi : .................................................................................................................................
Pemeriksaan Ekstremitas: Jari tabuh Sianosis Luka Infeksi kulit Edema
Pemeriksaan punggung: Deformitas vertebrae Infeksi
Status Neurologis: Status mental : ....................................................... Fungsi saraf kranial : I/II (RC, Visus)/III/IV/V/VI/VII/VIII/IX/X/XI/XII Kesadaran : E___ M___V___ Fungsi motorik sensorik: ..................................................
PEMERIKSAAN LABORATURIUMDarah rutin:
Hb : ....................................... Ht : ....................................... Leukosit : ........................................ Trombosit : ....................................... Eritrosit : ....................................... Diff count : .......................................
Fungsi Hati : SGPT : .................................................... SGOT : ....................................................
Fungsi Ginjal : Ureum darah : ...................................... Creatinin darah : .....................................
Gula Darah : ......................................................EKG:............................................................................................................................................
Spirometri: ...........................................................................................................................................
Echo: ..............................................................................................................................................................................................................................................................................................
Foto RX:..............................................................................................................................................................................................................................................................................................................
HASIL KONSUL BAGIAN LAINIPD:.............................................................................................................................................................................................................................................................................................................................
OBGYN:.......................................................................................................................................................................................................................................................................................................................
JANTUNG:...................................................................................................................................................................................................................................................................................................................
PARU:..........................................................................................................................................................................................................................................................................................................................
LAINLAIN:........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................KESIMPULANLAYAK OPERASI : YA/TIDAKASA : 1 2 3 4 5 6 E Dengan:................................................................
PERHITUNGAN KEADAAN DAN KEBUTUHAN CAIRAN Nama: ____________ BB:_____kgEBV (D/A: 70ml/kgbb B: 80ml/kgbb N: 90ml/kgbb)Jmlh Tranfusi darah (D >15 % EBV)WH:(Hbx – Hbpasien) x BB x 6=.....mlPRC:(Hbx – Hbpasien) x BB x3=......ml
