RUMAH SAKIT UMUM "MITRA SEHAT"

Jl. Wates Km.9 Ngaran, Balecatur, Gamping, Sleman, Yogyakarta

Telp. (0274) 6498555, 6498556, 08510038031 Fax. (0274) 6498555
HCU RSU "MITRA SEHAT" RM : Dari : Braden Score : APACHE II SCORE : Nutrion
NAMA :
Hari ke : Tanggal :
HIGH CARE UNIT
Special
TGL. LAHIR : Code
BB/TB : Gol. Darah : Total Calory
JENIS KELAMIN : L / P
INVASIVE DEVICE Allergies INVESTIGATION
Primary Doctor : DESCRIPTION DATE POSITION SIZE DESCRIPTION DATE TYPE Massage :
Consultant : Arterial Line
CVC LABORATORY
P.A. Catheter Antibiotic
ETT / Tracheostomy RADIOLOGI
Diagnosis :
Drainage
Type & Date Operation :
NGT CULTURE
Urine Catheter

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
TD S RR O2 N
200 40 100 20 100 200
TD
180 90 18 90 180

160 39 80 16 80 160 X SUHU

140 70 14 70 140
RR

120 38 60 12 60 120
X CVP
100 50 10 50 100
SpO2
80 37 40 8 40 80

NADI
60 30 6 30 60

40 36 20 4 20 40

20 10 2 10 20

0 35 0 0 0 0
CARDIOVASCULAR
CO / CI
PVR / PVRI
SVR / SVRI
ECG MONITORING

COMMENTS
RESPIRATORY 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
AIR EBTRY R / L AIR ENTRY :
MODE NV : Normal Vasicular
W : Wheezing
MV / EMV
R : Rhonchi
TV / ETV
MODE :
RATE / IMV NC : Nasal Canul
TOTAL RATE RM : Rebriding
INPIRASI PRESSURRE Masker
M k
PEEP / EXP PRESSURE NRM : Non Rebriding
Masker
PEAK/AIRWAY PRESURE
Fio2 / O2
ETCO2
POSITION ETT

SUCTION

COMMENTS
NEURO R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L R L
PUPIL SIZE
PUPIL REACTION
GCS

COMMENTS
NURSING
POSITION
EYE CARE
MOUTH CARE
PARINEAL CARE
ANTI EMBOLITIC
SKIN INTEGRITY

COMMENTS
PAIN ASSESMENT
LOCATION
INTENSITY
SKALA NYERI
SEDATION

COMMENTS

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
INTAKE (1) I I I I I I I I I I I I I I I I I I I I I I I I TOTAL
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
HORLY TOTAL
RUNNING TOTAL IN
METABOLISME / 24 HOURS
TOTAL INTAKE / 24 HOURS

OUTPUT (0) O O O O O O O O O O O O O O O O O O O O O O O O
DRAIN 1
DRAIN 2

NGT
DEFECATION
URINE
HOURLY TOTAL
RUNNING TOTAL
IWL / 24 HOURS
TOTAL OUTPUT / 24 HOURS
BALANCE
YESTERDAY PREVIOUS PREVIOUS
FLUID BALANCE

COMMENTS

LABORATORY

NURSE NAME