laporan jaga 18 0x1 2016 theo

8/20/2019 Laporan Jaga 18 0x1 2016 Theo

1/21


2/21

Pa%ie# 1

Nama : -#. -P

Um( : 2/ $a"#

Je#i% Kelami# : Lakilaki

Alama$ : Ka#$a# &i#i#i

-a#al R& : 13 Ja#a(i 2016


3/21

Kel"a# U$ama:

N,e(i pe($ ,a# mem)e(a$ %e*ak 1 "a(i &R&

RP& :

1 mi# &R&4 pa%ie# me#el"ka# #,e(i pe($. N,edi(a%aka# m#5l $i)a$i)a4 #,e(i pe($ di(a%aka# "ila#

$idak )e(k(a# de#a# i%$i(a"a$4 #,e(i di(a%aka# di pe($. Pa%ie# *a me(a%aka# pe($ $ea#. Demam 74"a(i &R&. Pa%ie# me#ak %li$ 9A94 da# me#el"ka# $i)a# a#i#. Pa%ie# kemdia# )e(o)a$ ke R&UD -alk da# didia#o%a Ile% O)%$(k$i'4 kemdia# pa%ie# di(*k kA(i# A5"mad


4/21

RP&

Riwayat Penyakit Dahulu

•

Pa%ie# $idak pe(#a" me#el"ka# kel"a# ,a# %ama %e)elm#,a• Ri+a,a$ "ipe($e#%i4 D4 a%ma da# pe#,aki$ *a#$# di%a#kal

Riwayat Penyakit Keluarga

• Ri+a,a$ H-4 D4 a%ma da# pe#,aki$ *a#$# dalam kela(a di%a#kal

Riwayat ekonomi, sosial, dan kebiasaan• Pa%ie# )eke(*a %e)aai pea+ai %+a%$a4 ke)ia%aa# me(okok da# mi#m a

di%a#kal

Ri+a,a$ ope(a%i

• Pa%ie# $idak pe(#a" diope(a%i %e)elm#,a


5/21

A : ale(i maka#a# da# o)a$o)a$a#

: pa%ie# $idak %eda# me#o#%m%i o)a$o)a$a#

P : (i+a,a$ H-4 a%ma4 pe#,aki$ *a#$# $idak ada

L : pa%ie# $e(ak"i( maka# *am 1


6/21

PEMERIKSAAN FISIK

&-A-U& G=N=RALI&

Keadaa# mm : $ampak %aki$ %eda#

Ke%ada(a#: kompo%me#$i%

-a#da $a#da >i$al :

-D : 120?80 mmH

Nadi : 82 @?me#i$

F(eke#%i #a'a% : 20 @?me#i$

&" : 64/ o5

&$a$% i!i :

99 : 68 k

-9 : 130 5m

I-: 24/ #o(mo+ei"$


7/21

AIRA!

Blea(4 pa%ie# dapa$ )e()i5a(a de#a# la#5a(4 $idak ada %m)a$a# *ala# #apaada %a(a #apa% $am)a"a#4 "em)%a# #apa% dapa$ di(a%aka#4 $idak ada #a"id#.

"ook : $idak $ampak kelai#a#

E>ala$e: *a(ak a#$a(a ii %e(i a$a% da# )a+a" *a(i4 *a(ak a#$a(a da

da# $la# $i(oid *a(i4 *a(ak a#$a(a )e#*ola# $i(oid da# da%a( ml$ 2 *a(i

Mallompa$, : (ade 1

#)%$(5$io#: $idak ada %m)a$a# *ala# #apa%

Ne5k mo)ili$, : le"e( dapa$ )e(e(ak )e)a%

$REA%&IN'

F(eke#%i #apa% : 20 @?me#i$4 (ela(4 )e#$k da# e(akka# di#di# dada %$idak ada (e$(ak%i ia da# pe##aa# o$o$ )a#$ pe(#apa%a#

&a(a #apa% : >e%ikle( 7?74 (o#k"i ?4 +"ee!i# ?


8/21

$"##D

Ak(al : ak(al "a#a$4 me(a"4 ke(i#

F(eke#%i #adi : 82 @?me#i$

-D : 120?80 mmH

BR- : C 2 de$ik

Ko#*#$i>a : $idak a#emi%

&kle(a : $idak ik$e(ik

$RAIN

Ke%ada(a# : ke%ada(a# kompo%me#$i%GB& : 1/

$"ADDER

P(odk%i (i# 74 U(em: /34/ m?dl4 B(ea$i#i#: 2413 m?dl


9/21

$#E"

I#%pek%i : pe($ $ampak da$a(4 %5a(

A%kl$a%i : )i%i# %% 7 /@

Pe(k%i : $impa#i

Palpa%i : %pel4 #,e(i $eka# epia%$(im

$#NE

-(ama 4 '(ak$(


10/21

Da(a" ($i# Kimia da(a"

H) : 1340 (?dl U(em : /34/ m?dlH- : /14< K(ea$i#i# : 2413 m?dl

E9B : 3.300 mm

-(om)o%i$ : 268.000 L

B- : 6

9- : 140

PEMERIKSAAN PEN(N)AN'


11/21

DIA'N#SA KER)A * Ile% O)%$(k$i'

REN+ANA %A%A "AKSANA * Lapa(a$om,

REN+ANA %INDAKAN ANES%ESI * Ge#e(al a#e%$"e%ia de#a# $ekGA=-

S%A%(S ASA * A&A I


12/21

PERSIAPAN ANES%ESI *

Pe(%iapa# pa%ie#

Pa%ie# di*ela%ka# $e#$a# p(o%ed( (e#5a#a $i#daka# a#e%$e%i GA

Pa%ie# dimi#$a pa%a 6 *am %e)elm ope(a%i

Pa%ie# dimi#$a melepa%ka# ii pal%4 pe("ia%a# da# )e%i)e%i laa$a meleka$ pada $)" pa%ie#

Pada pa%ie# dipa%a#ka# ak%e% i#$(a>e#a de#a# IV 5a$e$e( #o. 2$(a#%'%i de#a# loadi# 5ai(a# k(i%$aloid4 pa%$ika# 5ai(a# me#e$e%

Pakaia# pa%ie# dilepa% da# dia#$i de#a# )a* ope(a%i

Pa%ie# dipo%i%ika# $id( $e(le#$a#

Dikama( ope(a%i4 pada pa%ie# dipa%a#ka# %p",moma#ome$e( %a$(a%i O2. =>ala%i #adi4 $eka#a# da(a" da# %a$(a%i 02 p(eope(a


13/21

Pe(%iapa# ala$

empe(%iapka# me%i# a#e%$e%i4 mo#i$o(4 %ela# pe#")# 5o'a5e ma%k4 %p",moma#ome$e(4 %e#%o( %a$(a%i 024 mema%$ika# %

02 da# N20 $e(")# ke %m)e( %e#$(al4 me#i%i pe#" %e>o(a#5e da# i%o(a#5e

empe(%iapka# %$e$o%kop4 aa# 7 )lade la(i#o%kop 7 =-- *e#i%#omo( /.04 edel4 pla%$e( "ipa@ 2 lem)a( k(a# 14/ @ 1/ 5m 7k(a# / @ 5m4 i#$(od5e(4 5o##e5$o(4 ko$ak da# %ela# %5$io#55

empe(%iapka# %pi$ o)a$ 554 / 55 da# 10 55Ala$ i#'%e 5o#$i#e


14/21

Pe(%iapa# o)a$

Fe#$a#,l 3/ m5

P(opo'ol /0 m

A$(a5(im )e%,la$e 10 mO2 2l?me#i$4 N2O 2l?me#i$4 %e>o(a#5e 2>ol

Ke$o(ola5 0 m

-(amadol /0 m


15/21

Premedikasi

B$": )ol% 'e#$a#,l 3/ m5

#ksigenasiB$": ali(ka# O2 / L?me#i$ melali face mask da# ali(ka# ke depa# +a*a" pa%ie#

Induksi

B$": )ol% p(opo'ol /0 m4 pe(ik%a (eek )l ma$a "i#a #ea$i'

-entilasi . In/eksi mus0le rela1ant

Ka%ai pa$e#%i *ala# #a'a% pa%ie# de#a# 5a(a me#ek%$e#%ika# kepala pa%ie#4 pa%a#

#$k me#5ea" lida" me#,m)a$ *ala# #a'a% pa%ie#

Pa%a# facemask da# )e(i ali(a# O2 2L? me#i$4 N2O 2L? me#i$ da# i%o'o(a#e 2 >ol

Ve#$ila%i %e5a(a ma#al4 e>ala%i pe(e(aka# di#di# dada da# %a$(a%i O 2

&e$ela" *ala# #a'a% dapa$ dika%ai de#a# )aik4 )ol% a$(a5(im )e%,la$e 10 m4 kem

la#*$ka# >e#$ila%i ma#al %elama / me#ii$

%aha2an Anestesi *


16/21

"aringosko2i

Lepa%ka# facemask da# edel

Pa%a# )lade pada aa# la(i#o%kop da# pea# la(i#o%ko$a#a# ki(i

Po%i%ika# kepala pa%ie# ek%$e#%i

a%ka# la(i#o%kop ke dalam ml$ pa%ie# da(i %i%i ka#a#4 %lida" ke ki(i4 $el%(i lida" pa%ie# "i#a $e(li"a$ epilo$i% >o5ali%


17/21

Intubasi

a%ka# =-- #o /.0 de#a# $a#a# ka#a# ke a(a" pli5a >o5ali%

&am)#ka# *# =-- de#a# %ela# me%i# a#e%$e%i

Pa%$ika# =-- $ela" ma%k ke $(akea de#a# 5a(a li"a$ pe(e(akadada %ime$(i% da# a%kl$a%i pa( de#a# %a(a #a'a% ,a# %ampada lapa#a# pa( ka#a# da# ki(i %aa$ memompa )alo#

Fik%a%i i#$e(#a =-- de#a# me#em)a#ka# )alo# =-- me#da(a da# %pi$ 20 ml da# k%a%i ek%$e(#a de#a# me##aka

-$p ma$a pa%ie# de#a# "ipa@

Pa%a# del pada pa%ie#

U)a" %e$$i# me%i# a#e%$e%i da(i ma#al %po#$a# ke IPPV %po#$a


18/21

Maintenan0e

O2 2 L?me#i$

N2O 2L?me#i$

I%oo(a#e 2 >ol

%era2i 0airan

Ke)$"a# 5ai(a# mai#$e#a#5e pe( *am

< ml ? k 99? *am @ 10 k


19/21

Ke)$"a# 5ai(a# pe#a#$i pe#apa# pe( *am O

9e(a$ : 8 ml ? k99? *am @ 68 k

/


20/21


21/21

Post #2erasi

Pa%ie# %ada( lepa%ka# edel pi#da"ka# ke Re5o>e(, RoomRR

Pa#$a --V $iap 1/ me#i$4 PONV da# %kala VA&

Ok%ie#a%i 2L? me#i$ >ia #a%al 5a#l

D(ip a#ale$ik po%$ ope(a%i 20 $pm

9e(i 5ai(a# (ma$a# RL 20 $pm

Pa%a "i#a )i%i# %% po%i$i'

Pi#da"ka# ke (a#a# )ila ALD=R=-= %ko( 8

laporan jaga 18 0x1 2016 theo

Documents