CHECKLIST SUPERVISI PELAKSANAAN ANESTESI,

SEDASI MODERAT DAN DALAM

JENIS PELAYANAN DILAKUKAN TDK DILAKUKAN

I ANASTESI UMUM

Persiapan Pasien

1 Memasti an i!entitas pasien

" Memasti an a ses intra#ena $er%&n'si !en'an $ai

( Memasti an )n!isi %isi !an e*en' apan a!ministrasi

tera +ir

Memasti an m)nit)r pasien ses&ai !en'an

e$&t&+an $er%&n'si $ai

- Memasti an mesin !an per*en' apan anastesi $er

%&n'si !en'an $ai

. Men/e!ia an )$at )$at preme!i asi, in!& si !an

peme*i+araan ses&ai !en'an e$&t&+an !an )n!isi pasien

0 Preme!i asi ses&ai e$&t&+an

Pasti an terse!ia )$at2 )$atan emer'ensi

Pe*a sanaan Anestesi Um&m

1 Pasien mas& amar )perasi

" Di*a & an m)nit)rin' ses&ai !en'an )n!isi !an

e$&t&+an pasien

( Di$eri an )$at2 )$atan anestesi in!& si !an peme*i+araan

ses&ai !en'an e$&t&+an !an )n!isi pasien

Te ni pem$erian )$at peme*i+araan anestesi !ises&ai

an !en'an )n!isi pasien !an 3enis )perasin/a

Pen'a +iranAnestesia

1 Mem$eri an )$at ana*'esi4 !an pen4e'a+an m&a*

m&nta+ ses&ai e$&t&+an !an )n!isi pasien
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" O$at2)$at peme*i+araan anestesi !i+enti an sete*a+ )

perasi se*esai

TOTAL

HASIL DALAM PROSENTASE

JUMLAH 56YA66
?1@@ B
JUMLAH 66YA667 JUMLAH 56TIDAK66

T'i8$*n8t+n S&per#isi9::::::::;

Jam S&per#isi 9::::::::;

KEPALA RUAN>AN PELAKSANA SUPERVISI

Kamar Operasi

<Ya/at N&r+a/ati, S;Kep;,Ners= < !r Sri L&4/ N)#ita, SpAn=

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Persiapan Pasien

1 Memasti an i!entitas pasien

" Memasti an a ses intra#ena $er%&n'si !

en'an $ai

( Memasti an )n!isi %isi !an e*en' apan

a!ministrasi tera +ir

Memasti an m)nit)r pasien ses&ai !

en'an e$&t&+an $er%&n'si $ai

- Memasti an mesin !an per*en' apan

anastesi $er%&n'si !en'an $ai

. Men/e!ia an )$at )$at preme!i asi, in!& si

!an peme*i+araan ses&ai !en'an e$&t&+an !an
)n!isi pasien

0 Preme!i asi ses&ai e$&t&+an

Pasti an terse!ia )$at2 )$atan emer'ensi

Pe*a sanaan anastesi re'i)na*

1Pasien mas& amar )perasi

" Di*a & an m)nit)rin' ses&ai !en'an )n!isi !an

e$&t&+an pasien

( Me*a & an tin!a an anestesi re'i)na* ses&ai

!en'an e$&t&+an !an )n!isi pasien

Te ni pem$erian )$at peme*i+araan

anestesi !ises&ai an !en'an )n!isi pasien !
an 3enis )perasin/a

Per&$a+an Te ni Anestesi

1 Apa$i*a ter3a!i e'a'a*an te ni anestesi

re'i)na* a an !i*an3&t an !en'an te ni
anestesi &m&m
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JUMLAH 56YA66
?1@@ B
JUMLAH 66YA667 JUMLAH 56TIDAK66

T'i8$*n8t+n S&per#isi9::::::::;

Jam S&per#isi 9::::::::;

KEPALA RUAN> KAMAR OPERASI PELAKSANA SUPERVISI

<Ya/at N&r+a/ati, S;Kep;,Ners= < !r; Sri L&4/ N)#ita, Sp;An =

NO JENIS PELAYANAN DILAKUKAN TDK DILAKUKAN

III ANESTESI LOKAL

1 Sete*a+ pasien men'isi !an menan!atan'ani *em$ar

in%)rm 4)sent pet&'as men/iap an a*at &nt&
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( Pet&'as men''&na an sar&n' tan'an

Mem$ersi+ an area /an' a an !i*a & an

anestesi !en'an asa steri*

- Memasan' ain steri* &nt& memper e4i*

r&an' tin!a an

. Memas& an 3ar&m pa!a &3&n' *aserasi ata& *& a

!an !)r)n' mas& ea ra+ $a a+ ata& m& )sa !an
&*it sepan3an' *& a men'i &ti 'aris !imana 3ar&m
3a+itn/a a an mas& ata& e*&ar

0 Aspirasi em&!ian in3e si an anestesi terse$&t

sam$i* menari 3ar&m e titi !imana 3ar&m mas&
ata& 3i a ti!a !i*a & an aspirasi ma a sete*a+
sp&it !imas& an sampai e!a*am em&!ian !itari
sam$i* !isempr)t an per*a+an *a+an

Henti an pen'in3e sian anestesi ata& 3ar&m

!i$e*) an em$a*i sepan3an' 'aris *ain !imana
!iren4ana an a an !i$&at 3a+itan

U*an'i pr)ses pen&s& an se+in''a se*&r&+ !

aera+ /an' a an !i3a+it s&!a+ !i anestesi

1@ T&n''& $e$erapa *ama sam$i* me*a & an

pene anan pa!a *& a

11 Tan/a an pa!a pasien merasa n/eri ata& ti!a

se$e*&m me*a & an pen3a+itan ata&
pem$e!a+an min)r

TOTAL

HASIL DALAM PROSENTASE

JUMLAH 56YA66
?1@@ B
JUMLAH 66YA667 JUMLAH 56TIDAK66
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KEPALA RUAN> KAMAR OPERASI PELAKSANA SUPERVISI

<Ya/at N&r+a/ati, S;Kep;,Ners= < !r; Sri L&4/ N)#ita, Sp;An=

NO JENIS PELAYANAN DILAKUKAN TIDAK

DILAKUKAN

IV SEDASI SEDAN> <MODERAT=

Persiapan Pasien

1 D) ter anestesi me*a & an anamnesis !an pemeri

saan ea!aan &m&m <Ses&ai assessment pre
anestesi !an pre in!& si=

" D) ter anestesi mem$eri an pen3e*asan tentan' +a*2

+a* /an' a an !i*a & an epa!a pasien !an e*&ar'a
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se!asi <!e asa . 3am !an ana 2ana 3am=

Pe*a sanaan se!asi m)!erat

1 Pera at anestesi mempersiap an a*at !an )$at

O$at2 )$atan &nt& se!asi <mi!aF)*am,
atr)pine, s&*%as, )pi)i!=
Sp&it
M)nit)r <nasi,
sat&rasi= O si'en
Pera*atan !an )$at
res&sitasi Re am me!is
Am$&$a'8 #enti*asi te anan p)siti%
" Pera at anestesi men'at&r p)sisi pasien !an !
ipasan' m)nit)r

( Pera at anestesi memasan' ) si'en (2-L8 menit

Pera at anestesi memas& an )$at ses&ai instr& si !)

ter $e!a+

- D) ter anestesi !an ata& pera at anestesi

memantai +em)!inami !an men4atat !a*am re am
me!is se*ama pem$i&san

. Sete*a+ tin!a an se*esai, !) ter anestesi men'a asi

pasien +in''a sa!ar

0 Apa$i*a pasien +em)!inami sta$i* !an na%as a!e &at

*a*& !ipin!a+ e r&an' p&*i+ sa!ar <RR=

Pera at anestesi merapi an a*at

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Jam S&per#isi 9::::::::;

KEPALA RUAN> KAMAR OPERASI PELAKSANA SUPERVISI

<!r; Sri L&4/ N)#ita, Sp;An =

<Ya/at N&r+a/ati, S;Kep;,Ners=

NO JENIS PELAYANAN DILAKUKAN TIDAK

DILAKUKAN

IV SEDASI DALAM
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1 Pera at anestesi mempersiap an a*at !an )$at

O$at2 )$atan &nt& se!asi !an anestesi <pr)p)%)*,
mi!aF)*am, etamine, %entan/*, m)r%in, pet+i!in=
O$at2 )$atan anti!)t&m <na*) s)n8 n) )$a=
O$at2 )$atan res&sitasi <s&*%as atr)pine,
eprine%rin, e%e!rin, !eGametas)n,
am)n)p+i*in, !)pemin=
Sp&it
M)nit)r <nasi, sat&rasi,
tensi= O si'en
Mesin anestesi !an #enti*at)r
Pera*atan int&$asi
Re am me!is
Am$&$a'8 #enti*asi te anan p)siti%
" Pera at anestesi men'at&r p)sisi pasien !an !
ipasan' m)nit)r

( Pera at anestesi memasan' ) si'en ses&ai e$&t&+an

Pera at anestesi memas& an )$at &nt& se!asi !a*am

- D) ter anestesi !an ata& pera at anestesi

memantai +em)!inami !an men4atat !a*am re am
me!is se*ama pem$i&san

. Sete*a+ tin!a an se*esai, !) ter anestesi men'a asi

pasien +in''a sa!ar

0 Apa$i*a pasien +em)!inami sta$i* !an na%as a!e &at

*a*& !ipin!a+ e r&an' p&*i+ sa!ar <RR=
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Jam S&per#isi 9::::::::;

KEPALA RUAN> KAMAR OPERASI PELAKSANA SUPERVISI

<Ya/at N&r+a/ati, S;Kep;,Ners= <!r; Sri L&4/ N)#ita, Sp;An =