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Lampiran 1: Formulir Pengambilan Data

No. MR :

No. Status :

Nama Pasien :

Tanggal Operasi :

Ruang Inap :

Waktu pemberian anestesi spinal :

Jenis jarum spinal yang digunakan :

Tindakan :

Status fisik : ASA I/ASA II

Data Demografis:

Usia (tahun) :

Jenis kelamin :

Berat Badan :

Pekerjaan :

Alamat :

No. Telepon :
PENILAIAN PASCA OPERASI

Nyeri PDPH (onset)

Tingkat
Periode Inspeksi Tanggal Pukul PDPH
Keparahan
12 jam pasca injeksi spinal WIB

24 jam pasca injeksi spinal WIB


48 jam pasca injeksi spinal WIB
72 jam pasca injeksi spinal WIB
>72 jam pasca injeksi spinal WIB

Keterangan pengisiian kolom:


 Pukul = waktu insersi tusukan ditambah jam yang sudah ditentukan
 PDPH = diisi ( + ) bila PDPH dijumpai, dan ( - ) bila PDPH tidak dijumpai
 Tingkat Keparahan = diisi menurut nomor pada tabel dibawah sesuai
dengan keluhan

Tingkat Keparahan PDPH

Ringan
terjadi karena duduk dalam jangka waktu yang lama dan tidak ada gejala 1
yang lain.

Sedang
tidak mampu berdiri lebih dari setengah jam. Kadang-kadang diiringi dengan 2
mual, muntah, gejala auditori dan okular.
Berat
setelah turun dari tempat tidur, berkurang jika berbaring ditempat tidur yang
horizontal. Sering diiringi dengan mual, muntah, gejala auditori dan okular 3
atau terjadi walaupun saat berbaring dan sangat diperburuk saat berdiri,
makan tidak memungkinkan karena mual dan muntah berulang.

Hari
Kriteria Diagnostik PDPH
1 2 3 4 5

Nyeri kepala yang timbul saat 15 menit duduk


atau membaik setelah 15 menit berbaring.

Salah satu dari gejala-gejala seperti kaku kuduk,


tinitus, hiperakusia, fotofobia, dan mual-muntah

Nyeri kepala muncul dalam 5 hari pertama


setelah menjalani punksi dura

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