PANDUAN PRAKTIK KLINIS (PPK) PROSEDUR TINDAKAN RS MITRA KELUARGA CIBUBUR BEKASI 2016 Prosedur Pemasangan Central Vena Catheter 1. Penge engert rti in n Kteter #en "entr$ %$& "e'& teter *ng %ite+,t (De!ni"i) n e%$+ #en 'e"r %i $e&er (#en -g$r intern t #en -g$r e"tern) %% (#en "'/$#in) $engn (#en '"i$i/) t ,& (#en e+r$i").11 2. In%i"i 1. Mnitring Tenn en "entr$ (/entr$ #en" ,re""re CP) 2. Pe+'erin Pe+'erin nti'iti/ nti'iti/ intr#en intr#en -ng3,n-ng3,n-ng ng 4. Pe+'erin Pe+'erin ntri"i ntri"i ,rent ,renter$ er$ -ng -ng3,n3,n-ng ng 5. Ke+t e+ter er, ,ii . Pe+'erin Pe+'erin 't 't *ng *ng /en%erng /en%erng +en*e' +en*e''n 'n ,&$e'it ,&$e'iti" i" %$+ #en ,erier (/"ti/) "e,erti7 C$/i+ /&$ri%e C&e+t&er,* 8*,ertni/ "$ine Pt""i+ C&$ri%e A+i%rne 6. P$" P$"+ +,& ,&er ere" e"i" i" 9. Di$*" $*"i" :. Trn"" rn""ii %r& %r& 'er$ 'er$ng ng ;. Ke't&n e't&n n n "e" intr# intr#en en *ng *ng 'er$ng 'er$ng t ter ter " +ener" 10.Ke't&n n t&er,* intr#en "t "e" #en ,erier ti% %i+nginn 4. Kntr In%i i"i ABSOLUT • • • • •
•
Pen$n %ri ,"ien Ine"i %i %er& ,e+"ngn
•
ri"i nt+i *ng "$it ,% $"i ,e+"ngn
•
•
S,erir #en /# "*n%r+e (e
RELATI=
•
Cg$,t&* Ine"i "i"te+i
•
#entri/$r ""i"t %e#i/e %i"e'e$& nn
•
Pre"en/e in%>e$$ing /t&eter" t ,/ing >ire" ,% %er& ,e+"ngn 1. P"ien % % n?t e e$rg %i %i-e$"n tt -n in in%i"i +,$i"i %n ,er>tn "e" #en "entr$ ter"e't. 2. Srt ,er"et ,er"et-n -n tin% tin%n n %ii"i %n %n %itn%t %itn%tngni ngni $e& $e& %ter ,e$"n tin%n (,ertr) %n ,"ien?e$rg. 4. A$t A$t *ng *ng %i" %i"i i, ,n n •
5. Per"i,n
•
Steri$e +" g$#e" n% g>n
•
Mnitr &e+%in+i
•
I $ine ,erier %engn ter,"ng /irn
•
Steri$e ,re, "$tin (e.g. /&$r&e
•
Steri$e %r,e"
•
•
L/$ ne"t&eti/ ("$$* 1 $i%/ine)
•
22@gge 1.@in/& nee%$e
•
. Pr"e%r Tin%n
S,it @+L "teri$e %engn -r+ 2@ r 40 nt ne"te"i $$
1:@ r 20@gge intr#en" /t&eter (#er nee%$e) n "*ringe r 1:@gge &$$>@'re nee%$e
•
Pre""re t'ing
•
Guidewire
•
N. 11 "/$,e$ '$%e
•
Central venous catheter >it& %i$tr
•
4.0 "tre n /tting nee%$e
5. Pe+"ngn "e" #en "entr$ &en%n* %i$n %i rng tin%n *ng %i$eng,i %engn +nitr EKG "ert $t %n 't re""it"i P"ien %i,"i"in gr $et #en "entr$ $e'i& ",er!"i$ %n +%& %i%,t. . P% ,e+"ngn "e" %i #.-g$ri" intern t "'$#i ,"ien +eneng e "i"i 'er$>nn %n ,% ,nggng ntr e% ",$ %i'eri 'nt$ ,enggn-$ "e&ingg $e&er "e%iit e"ten"i. 6. Penggnn $tr"ngr! 'i "e/r $ng"ng "t ,r"e%r +,n ti% $ng"ng ("e'e$+ ,r"e%r) %,t +e+'nt ,r"e%r ,e+"ngn "e" #en %n +engrngi +,$i"i. 9. A$t ,e$in%ng %iri +en/, +"er tt, e,$ '- tin%n %n "rng tngn "teri$ %i"i,n nt ,ertr 1. Ce "e+ ,er$tn "e'e$+ +$i. 2. Steri$i""i %n tt,i re *ng n %iin"er"i %engn "ngt &ti@&ti. 4. P$,"i "" "'/$#i$ri" %n /e &'ngnn* ,% in/i"r "tern$i". Bi$ -ri %ite+,tn "e/r "'/$#i$ri" ,% ,"i"i $ter$ ter%,t "" *ng -e$" ntr /$#i/$ %n /"t II. Gern -ri e r& +e%i$ +en- in/i"r "tern$i" %n -ri n ter&+'t ,% -ng +e%i$ /$#i/$. Ini %$& +. "'/$#i" *ng 'er-$n %ri /"t I +en- ,er+n inerir /$#i$ +e+'erin ,$ *ng 'i ,"i"i /"t I %i+n ter$et #en "'/$#i
5.
.
6.
9. :.
6. P"/ Pr"e%r Tin%n
9. Tingt E#i%n/e :. Tingt Re+en%"i ;. Pene$& Kriti"
10.In%itr Pr"e%r Tin%n 11.Ke,"tn
te+,e$n ,r'e USG *ng "%& %i$,i"i ,$"ti "teri$. Letn -ri te$n- ,% in/i"r "tern$i" %n i' -ri ,% %er& ,erte+n ntr /$#i/$ %n /"t I. In!$tr"i ne"te"i $$ ($i%in 1) %engn -r+ 2@gge 2 /+ $ter$ i' -ri %n 0 /+ e %$ e r& /$#i/$ t te,t %i $ter$ %ri in"er"i +. "'/$#i /"t I. en 'er-$n %i '>& /$#i/$ +en- in/i"r "tern$i". Gnn -r+ 1:@gge *ng &$" %engn "*ringe +$ +"n -r+ +en" $it %i'gin $ter$ i' -ri %n 0 /+ %i '>& /$#i$ *ng %i+"% nt +e+'t ,"i"i &*$ ,% 'gin 'e$ng in/i"r "tern$i". P"i"i -r+ &rint$ (,r$e$ %engn $nti) nt +en/eg& ,ne+t&r" %n 'e#e$ +eng&%, et" t e r& i ,"ien nt +en/eg& teter +" e r& $e&er. A",ir"i -r+ $e'i& %$ ,ert&nn -r+ "e/r /er+t ,% te,i '>& /$#i$. i ti% % %r& #en *ng ter",ir"i "ete$& ,en"n "+,i /+ tri ,e$n@,e$n "+'i$ %i",ir"i -i +"i& 'e$+ % -g $ngi "e$i $gi %n ,'i$ +"i& 'e$+ 'er&"i$ ,in%& e r& ntr$ter$ n tet,i ,eri" t t&r" %&$ "e'e$+ %i$n nt +e$i&t %n* ,ne+t&r" Bi$ %r& ter",ir"i + ,"i"i #en "'/$#i te$& %i%,tn %n n$ t -r+ "e$%inger %i,ert&nn ,% ,"i"in* %engn +nt, S",n >t ,"ng teter t %i$tr %n teter "e$n-tn* $e,"n >t Ln %engn &ti@&ti nt +eng&in%ri it +"n* %r nt it "e'in* -ng teter ti% %i'irn ter'.
1. Ce '&> ",ir"i %r& 'e'" +e$$i teter %n tete"n 'er-$n %engn $n/r. 2. Kntr$ $et teter %engn t t&r". 4. g e'er"i&n te+,t ,e+"ngn CC I?II?III?I A?B?C 1. 2. 4. 1. 2. 4. 1.
Dr. A&+% Irn S,.An (K) IC Dr. E%>in R"$i S,.An (K) IC Dr. M. R$* S,.An (K) IC Rntgen t&r< ,"t tin%n Cirn +eng$ir $n/r Dr& tertri %engn +%& &tt,7??>>>.,r/e%re"/n"$t./+?+e%i/$@ ,r/e%re"?/entr$@#en"@$ine@,$/e+ent@AN@012@ ,r/e%re.",<
2. =n%+ent$ Criti/$ Cre S,,rt =rt& E%itin 2009
1. Pengertin (De!ni"i)
2. In%i"i
PANDUAN PRAKTIK KLINIS (PPK) PROSEDUR TINDAKAN RS MITRA KELUARGA CIBUBUR BEKASI 2016 Prosedur Anestesia Umum Ane"te"i U++ %$& tin%n +eni%n r" n*eri?"it "e/r "entr$ %i"erti &i$ngn* e"%rn %n %,t ,$i& e+'$i (re#er"i'e$). K+,nen ne"te"i *ng i%e$ ter%iri 7 &i,nti n$ge"i re$""i tt. 1. Innt n "i +% 2. De>" *ng +e+i$i& ne"te"i ++ 4. Pe+'e%&nn* $" ? e""ten"i 5. Pen%erit "it +ent$ . Pe+'e%&n $+ 6. Pe+'e%&n %i+n ne"te"i $$ ti% ,rti" t ti% +e+"n 9.
4. Kntr In%i"i
Ri>*t ,en%erit t"i ? $ergi 't ne"te"i $$
:. Pen%erit %engn ,eng'tn ntig$nti Tergntng ee r+$gi ,% rgn *ng +eng$+i e$inn (&r" &in%rn ,e+in 't t %"i" %irngi?%itrnn). •
7 't Hepar ter&%, &e,r.
&e,tt"i?'t
*ng
t"i"
•
• •
•
5. Per"i,n
Jantung 7 't @ 't *ng +en%e,re"i +ir%? +enrnn $irn %r& rner. 7 't *ng %ie"re"i %i gin-$. Ginjal 7 't *ng +erng"ng "ere"i Paru ,r?'rn" Endokrin 7 &in%ri 't *ng +eningtn %r g$ %r&? &in%rn ,e+in 't *ng +erng"ng ""nn "r "i+,ti" ,% %i'ete" ,en*it basedow ren 'i" +en*e''n ,eninggin g$ %r&.
) ANAMNESIS 1. I%enti!"i ,"ien +i"$7 n++r $+t ,eer-n 'gin t'& *ng n %i,er"i ri>*t ,er"i "e'e$+n* 2. Inr+e% Cn"ent. 4. Ri>*t ,en*it *ng ,ern& t "e%ng %i%erit *ng +ngin %,t +en-%i ,en*$it %$+ ne"te"i ntr $in 7 ,en*it $ergi ,en*it ,r@ ,r rni ("+ 'rni$ 'rniti") ,en*it -ntng &i,erten"i ,en*it &ti %n ,en*it gin-$. 5. Ri>*t 't@'t *ng "e%ng t te$& %ignn *ng +ngin +eni+'$n inter"i %engn 't@ 't ne"te"i. . Ri>*t ,er"i %n ne"te"i *ng ,ern& %i$+i ,% >t *ng $$ 'er, $i %n "e$ng >t. A,& "t it +eng$+i +,$i"i "e,erti7 $+ ,$i& "%r +e+er$n ,er>tn inten"i ,"/ 'e%& %$$. 6. Ke'i"n 'r "e&ri@&ri *ng +ngin %,t +e+,engr&i -$nn* ne"te"i "e,erti 7 +er +in+ +in+n 'er$&$ ,e+i nr'. PEMERIKSAAN =ISIK Pe+eri"n e%n gigi@ge$igi tin%n ' +$t $i%& re$ti#e 'e"r "ngt ,enting nt %iet&i ,& n +en*$itn tin%n $ring",i int'"i. Le&er ,en%e %n -g n +en*$itn $ring",i int'"i. Pe+eri"n rtin $in "e/r "i"te+ti tentng e%n ++ tent ti% '$e& %i$e>tn "e,erti in",e"i ,$,"i ,er"i %n "$t"i "e+ "i"te+ rgn t'& ,"ien. lasi!kasi "tatus #isik K$"i!"i *ng $i+ %ignn nt +eni$i e'grn !"i "e"erng i$& *ng 'er"$ %ri The American Society of Anesthesiologists (ASA). K$"i!"i !"i ini 'n $t ,rirn ri"i ne"te"i ren %+, "+,ing ne"te"i ti% %,t %i,i"&n %ri %+, "+,ing ,e+'e%&n. Ke$" I 7 P"ien "e&t rgni !"i$gi ,"iitri 'ii+i Ke$" II 7 P"ien %engn ,en*it "i"te+i ringn t "e%ng.
Ter+" -g "e+ ,"ien *ng 'er"i :0 t&n. Ke$" III 7 P"ien %engn ,en*it "i"te+i 'ert "e&ingg ti#it" rtin ter't". Ke$" I 7 P"ien %engn ,en*it "i"te+i 'ert ti% %,t +e$n ti#it" rtin %n ,en*itn* +er,n n/+n e&i%,n "eti, "t Ke$" 7 P"ien "ert *ng %i,erirn %engn t tn, ,e+'e%&n &i%,n* ti% n $e'i& %ri 25 -+. P% 'e%& cito t e+ergen"i 'i"n* %i/nt+n &r E. PEMERIKSAAN LABORATORIUM . 1. Dr& 7 8' 8t &itng -eni" $e"it g$ngn %r& >t ,e+'en %n ,er%r&n. 2. Urine 7 ,rtein re%"i "e%i+en 4. =t t&r 7 tert+ nt 'e%& +*r 5. EKG 7 rtin nt +r 50 t&n . E$er$it (Ntri+ K$i+ C&$ri%) 6. Di$n ,e+eri"n &"" 'i$ % in%i"i+i"$7 .EKG 7 ,% n %n %e>" F 50t&n %engn tn%@tn% ,en*it r%i#"$er. '.=ng"i &ti ('i$ir'in r'i$in %"'.) 'i$ %i/rigi %n* gnggn ng"i &ti. /.=ng"i gin-$ (re+ retinin) 'i$ %i/rigi %n* gnggn ng"i gin-$. PERSIAPAN DI 8ARI OPERASI . OPERASI ELEKTI= 1. Peng"ngn $+'ng ,enting nt +en/eg& ",ir"i i"i $+'ng ren regrgit"i ? +nt&. Unt %e>" %i,"n 6@: -+ "e'e$+ ,er"i "e%ng n ? '*i 5@ -+. 2. Gigi ,$" ? ,rte"e $in &r" %itngg$n "e'' %,t +en*+'t -$n n" %n +enggngg. 4. Per&i"n %n "+eti &r" %i$e," ?%i&," "e'' n +enggngg ,e+ntn "e$+ ,er"i. 5. P"ien +" +r 'e%& +e+i ,in &"" 'er"i& %n $nggr %n +%& %i$e,". . Mintn i-in ,er"i %ri ,"ien t e$rgn*. 6. S%& ter,"ng -$r ? "e" intr#en +enggnn i# /t&eter rn +ini+$ 1: t +en*e"in e%n ,"ien %i+n %i,i$i& rn *ng ,$ing +"i+$ 'i" %i,"ng. . Pr"e%r Tin%n
1. Di$n ,e+"ngn +nitr tenn %r& n%i %n "tr"i O2 2. Di$n ,e+eri"n !"i $ng -i %ite+n ,er'&n %n ti% +e+nginn nt %i$n ,e+'e%&n e$eti + ,e+'e%&n %,t %itn% nt %i$n ,enge$$n $e'i& $n-t. 4. i ,"ien ge$i"&?/e+" %i'erin ,re+e%i"i7 .Mi%$+ %"i" 009@01 +g?gBB i# '.P%
n SA 00100@01 +g?gBB +i%$+ 01 +g?gBB et+in 4@+g?gBB i+ t "e/r intr #en SA 001 +g?gBB +i%$+ 009 +g?gBB 5. Se'e$+ %i$n in%"i %i'erin "igen 6 $iter?+enit %engn +"er (,re "igen"i) "e$+ +enit. . O't in%"i *ng %ignn "e/r intr#en7 .Ket+in (%"i" 1@2 +g?gBB) '.Pent&t$ (%"i" 5@ +g?gBB) /.Pr,$ (%"i" 1@2 +g?gBB) 6. P% ,en%erit '*i t n *ng 'e$+ ter,"ng "e" intr#en in%"i %i$n %engn in&$"i +e+i gent in&$"i *ng ti% irit"i t +erng"ng -$n n" "e,erti &$t&ne t "e#Hrne. 9. Se$+ in%"i %i$n +nitr tn% #it$ (tenn %r& n%i +,n "tr"i "igen). :. P% "" ,er"i *ng +e+er$n ,e+e$i&rn -$n n" %i$n int'"i en%tr/&e$ t'e. ;. Pe+e$i&rn ne"te"i %i$n %engn +enggnn "" tri" ne"te"i ('$n/e ne"t&e"i) *it 7 "e%"i n$ge"i %n re$""i. 10.Pe+e$i&rn ne"te"i %,t +enggnn gent #$ti$e (&$t&ne enHrne +,n i"Hrne) t TIA (Tt$ Intr#en Ane"te"i) %engn +enggnn et+in t ,r,$. 11.P% ,e+'e%&n *ng +e+er$n re$""i tt %i'erin ,e+e$i&rn %engn 't ,e$+,& tt nn %e,$ri""i.
6. P"/ Pr"e%r Tin%n
OPERASI DARURAT (EMERGENC) 1. Di$n ,er'in e%n ++ "e,ti+$ +ngin "e,n-ng ter"e%i >t. 2. Di$n ,e+eri"n $'rtri+ "tn%r% t ,e+eri"n ,enn-ng *ng +"i& +ngin %,t %i$n. 4. P% ,er"i %rrt %i+n ti% %i+nginn nt +enngg "ein $+ + ,eng"ngn $+'ng %i$n $e'i& ti %engn /r +erng"ng +nt& %engn ,+r!n t +e+"ng ,i, n"g"tri. 5. Di$n in%"i %engn +et%e r,i% "Jen/e in%/tin +enggnn ""ini$ $in %engn %"i" 1 2 +g ?gBB. . Pe+e$i&rn ne"te"i %n +nitring ne"te"i *ng $inn* "e"i %engn ,er"i e$eti 1. E"t'"i %i$n "ete$& ,en%erit "%r. 2. Sete$& ,er"i ,en%erit %ir>t %n %i$n ,eng>"n tn% #it$ "e/r ett %i rng ,e+$i&n. 4. Pen%erit %i,in%&n %ri rng ,e+$i&n e 'ng"$ "ete$& +e+en&i riteri (A$%rete "/re : nt ,en%erit %e>" t Ste>rt S/re nt ,en%erit '*i ? n).
9. Tingt E#i%n/e :. Tingt Re+en%"i ;. Pene$& Kriti"
10.In%itr Pr"e%r Tin%n
11.Ke,"tn
5. A,'i$ ,"t@,er"i %i,er$n ,eng>"n &e+%in+i "e/r ett + %i$n %i rng inten"i (ICU). I?II?III?I A?B?C 1. Dr. A&+% Irn S,.An (K) IC 2. Dr. E%>in R"$i S,.An (K) IC 4. Dr. M. R$* S,.An (K) IC Tn%@tn% $ini" nt e%$+n ne"te"i *ng ti% +e+%i 7 1. Peningtn tenn %r&. 2. Peningtn reen"i %en*t -ntng. 4. P"ien +engn*&?+ene$n %n +en*eringi. 5. Ter%,t ,ergern. . Bereringt. D'"n M.B.e%. D&r+ A. Penuntun Praktis Anestesi. EGC rt 1;;5 Gni">r Si$i"ti G. Farmakologi dan Terapi (Basic Therapy Pharmacology). A$i& B&"7 Bgin =r+$gi =KUI. rt 1;; Ltie SA %. Petunjuk Praktis Anestesiologi. E%i"i Ke%. Bgin Ane"te"i$gi %n Ter,i Inten"i =KUI. rt 2010 ert& M. PokokPokok Anestesi. EGC rt 2010 •
•
•
•
PANDUAN PRAKTIK KLINIS (PPK) PROSEDUR TINDAKAN
1. Pengertin (De!ni"i)
2. In%i"i
4. Kntr In%i"i
RS MITRA KELUARGA CIBUBUR BEKASI 2016 Prosedur Pemasangan $ahurkar T&e MA8URKAR 12=r. Kteter %'$e?tri,,$e $+en teter %iin%i"in nt &e+%i$i"i" %n ,&ere"i". 8$ ini %irn/ng nt %i$e>ti $irn /irn *ng t nt %i$i"i" t ,&ere"i" %engn +nt %ri $+en etig nt in" (tri,,$e $+en). 1. P$"+,&ere"i" 2. Di$*"i" ABSOLUT
•
Pen$n %ri ,"ien Ine"i %i %er& ,e+"ngn
•
ri"i nt+i *ng "$it ,% $"i ,e+"ngn
•
•
S,erir #en /# "*n%r+e (e
RELATI
•
Cg$,t&* Ine"i "i"te+i
•
#entri/$r ""i"t %e#i/e %i"e'e$& nn
•
Pre"en/e in%>e$$ing /t&eter" t ,/ing >ire" ,% %er& ,e+"ngn 1. P"ien %n?t e$rg %i-e$"n t-n in%i"i +,$i"i %n ,er>tn "e" #en "entr$ ter"e't. 2. Srt ,er"et-n tin%n %ii"i %n %itn%tngni $e& %ter ,e$"n tin%n (,ertr) %n ,"ien?e$rg. 4. A$t *ng %i"i,n Steri$e +" g$#e" n% g>n •
5. Per"i,n
•
•
Mnitr &e+%in+i
•
I $ine ,erier %engn ter,"ng /irn
•
Steri$e ,re, "$tin (e.g. /&$r&e
•
Steri$e %r,e"
•
S,it @+L "teri$e %engn -r+ 2@ r 40 nt ne"te"i $$
•
L/$ ne"t&eti/ ("$$* 1 $i%/ine)
•
22@gge 1.@in/& nee%$e
•
1:@ r 20@gge intr#en" /t&eter (#er
nee%$e) n "*ringe r 1:@gge &$$>@'re nee%$e
. Pr"e%r Tin%n
•
Pre""re t'ing
•
Guidewire
•
N. 11 "/$,e$ '$%e
•
$ahurkar dou%le&tripple lumen
•
4.0 "tre n /tting nee%$e
5. Pe+"ngn "e" #en "entr$ &en%n* %i$n %i rng tin%n *ng %i$eng,i %engn +nitr EKG "ert $t %n 't re""it"i P"ien %i,"i"in gr $et #en "entr$ $e'i& ",er!"i$ %n +%& %i%,t. . P% ,e+"ngn "e" %i #.-g$ri" intern t "'$#i ,"ien +eneng e "i"i 'er$>nn %n ,% ,nggng ntr e% ",$ %i'eri 'nt$ ,enggn-$ "e&ingg $e&er "e%iit e"ten"i. 6. Penggnn $tr"ngr! 'i "e/r $ng"ng "t ,r"e%r +,n ti% $ng"ng ("e'e$+ ,r"e%r) %,t +e+'nt ,r"e%r ,e+"ngn "e" #en %n +engrngi +,$i"i. 9. A$t ,e$in%ng %iri +en/, +"er tt, e,$ '- tin%n %n "rng tngn "teri$ %i"i,n nt ,ertr 1. Ce "e+ ,er$tn "e'e$+ +$i. 2. Steri$i""i %n tt,i re *ng n %iin"er"i %engn "ngt &ti@&ti. 4. P$,"i "" "'/$#i$ri" %n /e &'ngnn* ,% in/i"r "tern$i". Bi$ -ri %ite+,tn "e/r "'/$#i$ri" ,% ,"i"i $ter$ ter%,t "" *ng -e$" ntr /$#i/$ %n /"t II. Gern -ri e r& +e%i$ +en- in/i"r "tern$i" %n -ri n ter&+'t ,% -ng +e%i$ /$#i/$. Ini %$& +. "'/$#i" *ng 'er-$n %ri /"t I +en- ,er+n inerir /$#i$ +e+'erin ,$ *ng 'i ,"i"i /"t I %i+n ter$et #en "'/$#i te+,e$n ,r'e USG *ng "%& %i$,i"i ,$"ti "teri$. 5. Letn -ri te$n- ,% in/i"r "tern$i" %n i' -ri ,% %er& ,erte+n ntr /$#i/$ %n /"t I. In!$tr"i ne"te"i $$ ($i%in 1) %engn -r+ 2@gge 2 /+ $ter$ i' -ri %n 0 /+ e %$ e r& /$#i/$ t te,t %i $ter$ %ri in"er"i +. "'/$#i /"t I. . en 'er-$n %i '>& /$#i/$ +en- in/i"r "tern$i". Gnn -r+ 1:@gge *ng &$" %engn "*ringe +$ +"n -r+ +en" $it %i'gin $ter$ i' -ri %n 0 /+ %i '>& /$#i$ *ng %i+"% nt +e+'t ,"i"i
&*$ ,% 'gin 'e$ng in/i"r "tern$i". P"i"i -r+ &rint$ (,r$e$ %engn $nti) nt +en/eg& ,ne+t&r" %n 'e#e$ +eng&%, et" t e r& i ,"ien nt +en/eg& teter +" e r& $e&er. A",ir"i -r+ $e'i& %$ ,ert&nn -r+ "e/r /er+t ,% te,i '>& /$#i$. i ti% % %r& #en *ng ter",ir"i "ete$& ,en"n "+,i /+ tri ,e$n@,e$n "+'i$ %i",ir"i -i +"i& 'e$+ % -g $ngi "e$i $gi %n ,'i$ +"i& 'e$+ 'er&"i$ ,in%& e r& ntr$ter$ n tet,i ,eri" t t&r" %&$ "e'e$+ %i$n nt +e$i&t %n* ,ne+t&r" 6. Bi$ %r& ter",ir"i + ,"i"i #en "'/$#i te$& %i%,tn %n n$ t -r+ "e$%inger %i,ert&nn ,% ,"i"in* %engn +nt, 9. S",n >t ,"ng teter t %i$tr %n teter "e$n-tn* $e,"n >t :. Ln %engn &ti@&ti nt +eng&in%ri it +"n* %r nt it "e'in* -ng teter ti% %i'irn ter'. 6. P"/ Pr"e%r Tin%n
9. Tingt E#i%n/e :. Tingt Re+en%"i ;. Pene$& Kriti"
10.In%itr Pr"e%r Tin%n 11.Ke,"tn
1. Ce '&> ",ir"i %r& 'e'" +e$$i teter %n tete"n 'er-$n %engn $n/r. 2. Kntr$ $et teter %engn t t&r". 5. g e'er"i&n te+,t ,e+"ngn CC I?II?III?I A?B?C 1. 2. 4. 1. 2. 4. 1.
Dr. A&+% Irn S,.An (K) IC Dr. E%>in R"$i S,.An (K) IC Dr. M. R$* S,.An (K) IC Rntgen t&r< ,"t tin%n Cirn +eng$ir $n/r Dr& tertri %engn +%& &tt,7??>>>.,r/e%re"/n"$t./+?+e%i/$@ ,r/e%re"?/entr$@#en"@$ine@,$/e+ent@AN@012@ ,r/e%re.",< 2. =n%+ent$ Criti/$ Cre S,,rt =rt& E%itin 2009 4. &tt,7??>>>.en%$$&e$t&/re./+?,geBi$%er.",< /ntentID10:900>e'PgeID0t,i/ID95294' re%/r+'"07121624:1049706;;4270
