PELAKSANAAN PENILAIAN PRA ANESTESI PADA PASIEN DENGAN ANESTESI UMUM DI RUANG INSTALASI BEDAH SENTRAL RSUD BULELENG : STUDY KASUS DESKRIPTIF LUH GEDE SINTYA PRABAWATI Fakultas Kesehatan Program Studi DIV Keperawatan Anestesiologi Institut Teknologi Dan Kesehatan Bali Emai : [email protected] ABSTRAK Latar Belak ang : Pelayanan anestesi merupakan bagian dari pelayanan perioperatif yang memiliki pengaruh besar dalam menentukan keberhasilan tindakan pembedahan yang adekuat dan menghindari resiko cedera anestesi bagi pasien. Penata anestesi dalam menjalankan praktik keprofesiannya berwenang untuk melakukan pelayanan asuhan kepenataan anestesi pada penilaian pra anestesi. Tujuan : Untuk mengetahui pelaksanaan penilaian pra anestesi pada pasien dengan anestesi umum di ruang I nstalasi B edah S entral RSUD Kabupaten Buleleng. Metode : Penelitian ini menggunakan desain penelitian kualitatif , dan metode penelitian Multiple Case Studi dengan pendekatan Deskriptif . Jumlah partisipan dalam penelitian ini sebanyak 2 partisian yang memenuhi kriteria inklusi. Alat pengumpulan data menggunakan cheklist wawancara, lembar Observasi, dan lembar Dokumentasi Pelaksanaan Penilaian Pra Anestesi. Hasil : Hasil penelitian ini pada pemeriksaan anamnesis partisipan melakukan penilaian dengan menggunakan Foundamental Four dan Sacred Seven , pada pemeriksaan fisik partisipan tidak melakukan pemeriksaan IMT dan gangguan saraf tepi. Dan pada pendokumentasian pra anestesi partisipan menuliskan hasil penilaian di lembar dokumentasi pada saat durante operasi dan pasca operasi. Kesimpulan : Penata Anestesi dalam pelaksanaan penilaian anamnesa pasien, mengkaji pemeriksaan fisik, pemeriksaan penunjang dan psikis pasien berjalan hampir sesuai dengan SOP yang berlaku, kecuali pada pemeriksaan IMT, gangguan saraf tepi, memberikan salam terapiutik pengak hiran tindakan dan dalam pendokumentasian tindakan kurang mematuhi tatalaksana SOP yang berlaku, hal ini disebabkan karena singkatnya waktu saat pra anestesi. Kata kunci : Pra Anestesi, General Anestesi, Penata Anestesi, Penilaian Pra Anestesi.

THE IMPLEM ENTATION OF PRE - ANESTHESIA ASSESSMENT IN PATIENTS WITH GENERAL ANESTHESIA IN THE CENTRAL SURGICAL INSTALLATION OF BULELENG HOSPITAL : DESCRIPTIVE CASE STUDY LUH GEDE SINTYA PRABAWATI Faculty of Health Diploma IV Nursing Anesthesiology Program Institute of Technology and Health Bali Emai : [email protected] ABSTRACT Background: Anesthesia service is part of perioperative services that have a major influence in determining the success of adequate surgery and avoiding the risk of anesthesia injury for patients. The nurse anesthetist is authorized to provide care for anesthesia adm inistration in pre - anesthesia assessments in carrying out their professional practice . Aim: To identify the implementation of pre - anesthesia assessment in patients with general anesthesia in the Central Surgical Installation of Buleleng Hospital. Methods: This study employed a qualitative research design, and the research method is Multiple Case Study with a descriptive approach. There were 2 participants who met the inclusion criteria recruited as the sample . The data were collected by using interview chec klists, observation sheets, and Pre - Anesthesia Assessment Documentation sheets. Finding: The finding found that in the anamnesis, the participants assessed using the Foundational Four and Sacred Seven. In the physical examination, the participants did not examine BMI and peripheral nerve disorders. Mo r eover, in the pre - anaesthesia documentation, participants wrote down the results of the assessment on the documentation sheet during and after surgery. Conclusion: The nurse anesthetist carries out the assessment of the patient's anamnesis, reviewing the physical examination, support and psychological examination of the patient run almost according to the applicable SOP, except for the BMI examination, peripheral nerve disorder; further, the nur se anesthetist gives therapeutic greetings for ending the action and in documenting actions which is not comply with the applicable SOP management due to the limited time of pre - anesthesia . Keywords: Pre Anesthesia, General Anesthesia, Nurse Anesthetist, P re Anesthesia Assessment