FORMULIR MONITORING PASIEN TERPASANG VENTILATOR

Ruang : Tgl MRS :

Bulan/Tahun : Diagnosa :

Tan##al
Ventlaor
Ventlaor Bundle Preventon Checl!"
1 2 3 4 5 6 7 8 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
Intubasi
  )   n
!stubasi    a
   a
   a     !
    l
   i    +    u
"u#i tangan s$suai 5 %o%$nt    n    !
    b   a   a
    l
   9   t   i
&'al h(gi$n$ 2)3*/+a(  C
   a     +
    +   n     !
osisi !$.ala 30< ) 45<    n    a   a
    !
   a     +
   t   u   -
,an-/b$'sih!an .$'alatan bila +i.a!ai b$'sa%a    i    !
   '   a   a
   $    l
   i    l
   i
ai !$%a%.uan * b$'naas s$n+i'i    B    +    b

VENTILATOR
VENTILATOR ASSOC IATE$ EVENT
%in #%2&  I&2%in  'it$'ia B$'i tan+a  .a+a it$% (an
ilai %in tulis ag!a t$'$n+ah ha'ian
ilai i&2%in tulis ag!a t$'$n+ah ha'ian
   C S$la%a 2ha'i/l$bihC nilai %in atau i&2%in ha'ian stabil atau tu'un
   A
   V +is$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<"
B
>38<"
LEU%OSIT
   C 4000 ) 11?999/%%3
   A
   V
   I @12000/%%3
"
A4000/%%3
ANTI BIOTI% &ANG $IBERI%AN B$'i tan+a
tan+a  .a+a
.a+a it$%
it$% (an
(an
a%a ;b1 : ?
a%a ;b2 : ?
a%a ;b3 : ?
   e
SE%RESI TRAC'EA (SPUTUM)
    l
    ,
   a
Ti+a! a+a/ a+an non ) .u'ul$n
    ,
   o a+aC .u'ul$nt D
   r   P
   P 'a"!l Pe*er!"aan %ulur S+uu*
    -   A
    l
    , Ti+a! a+a .$'tu%buhan !u%an tu%buh ($ast/#an+i+a
   !
   "
   " ;+a .$'tu%buhan !u%an s$lain ($ast/#an+i+a 1
   o
   P Tu%buh !u%an s$lain ($ast/#an+i+a +$ngan u%lah = 10 "/%l 2

$t$'angan :
VAC: (Ventilator Associated Condition) : Nila memenuhi kriteria A 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$n +an bun+l$ .'$
IVAC: (Infection-related Ventilator-Associated Complication) : &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
VAC H 'it$'ia B +an C H ant,!ot ,aru %$na+i +$no%inato' .$'hitungan? Bila +i.$'lu!anC tulis +ata ta%bahan +i bagian !$t$'anganC %isaln(a na
Po""!,le VAP  F$n-lato' ;sso#iat$+ n$u%onia: s$nsi-Gtasn(a?
IVAC . %r!er!a $ aau E/
Pro,a,le VAP 0 IVAC . %r!er!a E1
 o'%ula $nghitungan ;ng!a $a+ian F; :

$n-on (ang +ila!u!an? Ju%lah .sn +gn F; *1000

!ibat .$%asangan E$n-lato'  u%lah ha'i .$%asangan E$n-lato'
+iisi? Total ha'i .$%asangan
%a !u%an hasil !ultu' +an Dibuat ol$hC M$ng$tahuiC

I" $a+ u's$