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Nama : Nama :

Tanggal : Tanggal :
Diagnosis : Diagnosis :

Maintenance (M) = 2cc x Kgbb = Maintenance (M) = 2cc x Kgbb =


Pengganti Puasa (PP) = M x Lama Puasa = Pengganti Puasa (PP) = M x Lama Puasa =
Stress Op (SO) = Derajat Keparahan x Kgbb = Stress Op (SO) = Derajat Keparahan x Kgbb =
Jam 1 : M + ½ PP + SO = Jam 1 : M + ½ PP + SO =
Jam 2 : M + ¼ PP + SO = Jam 2 : M + ¼ PP + SO =
Jam 3 : M + ¼ PP + SO = Jam 3 : M + ¼ PP + SO =
Jam 4 : M + SO = Jam 4 : M + SO =

Nama : Nama :
Tanggal : Tanggal :
Diagnosis : Diagnosis :

Maintenance (M) = 2cc x Kgbb = Maintenance (M) = 2cc x Kgbb =


Pengganti Puasa (PP) = M x Lama Puasa = Pengganti Puasa (PP) = M x Lama Puasa =
Stress Op (SO) = Derajat Keparahan x Kgbb = Stress Op (SO) = Derajat Keparahan x Kgbb =
Jam 1 : M + ½ PP + SO = Jam 1 : M + ½ PP + SO =
Jam 2 : M + ¼ PP + SO = Jam 2 : M + ¼ PP + SO =
Jam 3 : M + ¼ PP + SO = Jam 3 : M + ¼ PP + SO =
Jam 4 : M + SO = Jam 4 : M + SO =

Nama : Nama :
Tanggal : Tanggal :
Diagnosis : Diagnosis :

Maintenance (M) = 2cc x Kgbb = Maintenance (M) = 2cc x Kgbb =


Pengganti Puasa (PP) = M x Lama Puasa = Pengganti Puasa (PP) = M x Lama Puasa =
Stress Op (SO) = Derajat Keparahan x Kgbb = Stress Op (SO) = Derajat Keparahan x Kgbb =
Jam 1 : M + ½ PP + SO = Jam 1 : M + ½ PP + SO =
Jam 2 : M + ¼ PP + SO = Jam 2 : M + ¼ PP + SO =
Jam 3 : M + ¼ PP + SO = Jam 3 : M + ¼ PP + SO =
Jam 4 : M + SO = Jam 4 : M + SO =

Nama : Nama :
Tanggal : Tanggal :
Diagnosis : Diagnosis :

Maintenance (M) = 2cc x Kgbb = Maintenance (M) = 2cc x Kgbb =


Pengganti Puasa (PP) = M x Lama Puasa = Pengganti Puasa (PP) = M x Lama Puasa =
Stress Op (SO) = Derajat Keparahan x Kgbb = Stress Op (SO) = Derajat Keparahan x Kgbb =
Jam 1 : M + ½ PP + SO = Jam 1 : M + ½ PP + SO =
Jam 2 : M + ¼ PP + SO = Jam 2 : M + ¼ PP + SO =
Jam 3 : M + ¼ PP + SO = Jam 3 : M + ¼ PP + SO =
Jam 4 : M + SO = Jam 4 : M + SO =

Nama : Nama :
Tanggal : Tanggal :
Diagnosis : Diagnosis :
Maintenance (M) = 2cc x Kgbb = Maintenance (M) = 2cc x Kgbb =
Pengganti Puasa (PP) = M x Lama Puasa = Pengganti Puasa (PP) = M x Lama Puasa =
Stress Op (SO) = Derajat Keparahan x Kgbb = Stress Op (SO) = Derajat Keparahan x Kgbb =
Jam 1 : M + ½ PP + SO = Jam 1 : M + ½ PP + SO =
Jam 2 : M + ¼ PP + SO = Jam 2 : M + ¼ PP + SO =
Jam 3 : M + ¼ PP + SO = Jam 3 : M + ¼ PP + SO =
Jam 4 : M + SO = Jam 4 : M + SO =

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