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Flow Sheet Hcu Icu HND 2019

This document contains a 24-hour nursing care sheet for monitoring vital signs, intake and output, medications, and other treatments for a hospitalized patient. Key details include fields to record temperature, heart rate, blood pressure, oxygen therapy, intravenous fluids administered and output, diet, and neurological assessments hourly. Notes sections allow documentation of the patient's condition, care provided, and care plan. The sheet is used to comprehensively monitor the patient's status and care over a 24-hour period during hospitalization.

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Alfredo Kristian Goldie
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172 views31 pages

Flow Sheet Hcu Icu HND 2019

This document contains a 24-hour nursing care sheet for monitoring vital signs, intake and output, medications, and other treatments for a hospitalized patient. Key details include fields to record temperature, heart rate, blood pressure, oxygen therapy, intravenous fluids administered and output, diet, and neurological assessments hourly. Notes sections allow documentation of the patient's condition, care provided, and care plan. The sheet is used to comprehensively monitor the patient's status and care over a 24-hour period during hospitalization.

Uploaded by

Alfredo Kristian Goldie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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VAS

0 1 2 3 4 5 6 7 8 9
CPOT

Braden Scale

Persepsi sensorik
Kelembaban
Aktivitas
Mobilitas
Nutrisi
Tingkat friksi

Skor 15-18 resiko rendah


Skor 13-14 resiko sedang
Skor 10-12 resiko tinggi
Skor ≤9 resiko sangat tinggi

Well's Score u/ DVT


10
High Nursing Dependent/HIGH CARE UNIT/ICU
KAMAR TANGGAL Hari Rawat Ke DPJP UTAMA

Diagnosa masuk
Stiker Identitas Pasien DPJP
Alergi

06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 01.00 02.00 03.00 04.00 05.00 06.00
TD HR • FP ▲ S • NYERI •
MAP

350 200 100 41

300 180 90 40

250 160 80 39 10

200 140 70 38 8
HEMODINAMIK DAN TANDA - TANDA VITAL

150 120 60 37 6

100 100 50 36 4

50 80 40 35 2

0 60 30 34 0

40 20 33

20 10 32 2

0 0 31 0
GAMBARAN ECG

06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 01.00 02.00 03.00 04.00 05.00 06.00

UKURAN PUPIL
REAKSI PUPUIL
NEUROLOGI

KESADARAN KUALITATIF
STATUS

GCS ( E / M / V )
Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki: Tka: Tki:
KEKUATAN MOTORIK
Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki: Kka: Kki:
KEJANG Durasi / Tipe

MACAM-MACAM TERAPI
OKSIGEN ( Non
Terapi
O2

Invasif / Jenis ) `

Saturasi O2

CM : Cairan Masuk CA : Cairan Ada


06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 01.00 02.00 03.00 04.00 05.00 06.00
KOLOID / DARAH CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA

KRISTALOID CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA

TITRASI OBAT CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA
T A K E

PARENTERAL CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA
I N

SPOELING CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA CM/CA
VOLUME OBAT ≥ 50 CC

JUMLAH CAIRAN INTRAVENA


Enteral SV
Feeding Spoeling
DIET
Makan
Oral
Minum
JUMLAH CAIRAN DIET
TOTAL INTAKE
Jumlah
Muntah
Warna
Jumlah
CMS
Warna
P U T

Jenis
Drain
P U
Drain
Jumlah
Jumlah
O U T BAK
Warna
Hemodialisa
Konsistensi
BAB
Warna
IWL
TOTAL OUTPUT

TOTAL BALANCE
CM/CA

CM/CA

CM/CA

CM/CA

CM/CA
CATATAN PERKEMB
PROFESI
JAM
( Subyek
Diverifikasi Tanggal : ........./........../....... Tanda
ERKEMBANGAN PASIEN TERINTEG
S OAP

( Subyektif Obyektif Analisa Planning )


Tanda Tangan & nama DPJP Utama
ERINTEGRASI
NAMA
JAM
PARAF
IMPLEMENTASI KEPERA
IMPLEMENTASI
SI KEPERAWATAN
NAMA
NTASI

PARAF

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