Download - Laporan Jaga 18 0x1 2016 Theo
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Pa%ie# 1
Nama : -#. -P
Um( : 2/ $a"#
Je#i% Kelami# : Lakilaki
Alama$ : Ka#$a# &i#i#i
-a#al R& : 13 Ja#a(i 2016
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Kel"a# U$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
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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# $idak pe(#a" diope(a%i %e)elm#,a
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A : ale(i maka#a# da# o)a$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
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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"$
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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# ?
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$"##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
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$#E"
I#%pek%i : pe($ $ampak da$a(4 %5a(
A%kl$a%i : )i%i# %% 7 /@
Pe(k%i : $impa#i
Palpa%i : %pel4 #,e(i $eka# epia%$(im
$#NE
-(ama 4 '(ak$(
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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'
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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
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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
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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#$i#e
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Pe(%iapa# o)a$
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
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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 *
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"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%
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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#$a
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Maintenan0e
O2 2 L?me#i$
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
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Ke)$"a# 5ai(a# pe#a#$i pe#apa# pe( *am O
9e(a$ : 8 ml ? k99? *am @ 68 k
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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