FORMULIR MONITORING PASIEN TERPASANG VENTILATOR.xls

FORMULIR MONITORING PASIEN TERPASANG VENTILATOR Ruang : Bulan/Tahun :

Tgl MRS : Diagnosa : Ventlaor Ventlaor Bundle Preventon Checl!"

Intubasi !stubasi "u#i tangan s$suai 5 %o%$nt &'al h(gi$n$ 2)3*/+a( osisi !$.ala 30< ) 45< ,an-/b$'sih!an .$'alatan bila +i.a!ai b$'sa%a ai !$%a%.uan * b$'naas s$n+i'i

1

2

3

4

5

6

7

8

Tan##al 9 10 11 12 1 2 13 1 3 14 1 4 15 16 1 6 17 1 7 18 1 8 19 1 9 20

  )   n    a    a    a     !     l    u    i    +     !    n     b   a   a     l    9   t   i  C    a     +     !     +   n    a   a    n     !     +    a    t   u      i    !    '   a   a     l    $    i    l    i    B     +     b

VENTILATOR VENTILATOR ASSOC IATE$ EVENT

%in #%2&  I&2%in  ilai %in tulis ag!a t$'$n+ah ha'ian ilai i&2%in tulis ag!a t$'$n+ah ha'ian    C    A    V

'it$'ia

B$'i tan+a  .a+a it$% (an

S$la%a 2ha'i/l$bihC nilai %in atau i&2%in ha'ian stabil atau tu'un +is$but .$'io+$ stabil S$t$lah .$'io+$ stabilC nilai %in nai! = 3#% 2& atau i&2%in nai! = 20 +a'i nilai %in atau i&2%in .a+a .$'io+$ stabil

;

TEMPERATUR

36<" ) 38<" =38<" >38<"

B LEU%OSIT

   C    A    V    I

   e     l     ,    a     ,    o    r   P    P     -   A

4000 ) 11?999/%%3 @12000/%%3 A4000/%%3 ANTI BIOTI% &ANG $IBERI%AN a%a ;b1 : ? a%a ;b2 : ? a%a ;b3 : ? SE%RESI TRAC'EA (SPUTUM) Ti+a! a+a/ a+an non ) .u'ul$n a+aC .u'ul$nt 'a"!l Pe*er!"aan %ulur S+uu*

" B$'i tan+a tan+a  .a+a .a+a it$% it$% (an (an

D

    l     ,    !    "    "    o    P

Ti+a! a+a .$'tu%buhan !u%an tu%buh ($ast/#an+i+a ;+a .$'tu%buhan !u%an s$lain ($ast/#an+i+a Tu%buh !u%an s$lain ($ast/#an+i+a +$ngan u%lah = 10 "/%l

1 2

$t$'angan : VAC:

(Ventilator Associated Condition) : Nila memenuhi kriteria A (Infection-related Ventilator-Associated Complication) :

IVAC:

VAC H 'it$'ia B +an C H ant,!ot ,aru Po""!,le VAP  F$n-lato' ;sso#iat$+ n$u%onia: IVAC . %r!er!a $ aau E/ Pro,a,le VAP 0 IVAC . %r!er!a E1

Bila .asi$n t$'.asang E$n-lato' C l$ng!a.i o'% su'E$ilans F; s$suai !on+isi ha'ian .asi$n +an bun+l$ .'$ &bs$'Easi ha'ian +i.$'lu!an untu! %$ng$tahui s$#a'a .as- ha'i !$ b$'a.a .asi$n %$ngala%i .n$u%onia +an b$'a.a la%a -a. .asi$n t$'.asang E$n-lato'? S$b$lu% +is$'ah!anC ha'a. !olo% total ha'i .$%asanga %$na+i +$no%inato' .$'hitungan? Bila +i.$'lu!anC tulis +ata ta%bahan +i bagian !$t$'anganC %isaln(a na s$nsi-Gtasn(a?

a%a Tgl?ahi' o?RM ;la%at

: : : :

21 22 23 24 25 26 27 28 29 30 31

 

s$suai

 

s$suai

Toal (har!)

%eeran#an

o'%ula $nghitungan ;ng!a $a+ian F; : $n-on (ang +ila!u!an? !ibat .$%asangan E$n-lato' +iisi? Total ha'i .$%asangan %a !u%an hasil !ultu' +an

Ju%lah .sn +gn F; *1000  u%lah ha'i .$%asangan E$n-lato' Dibuat ol$hC M$ng$tahuiC

I"

$a+ u's$