| mays ana sumone my | 031702 07/07/1953 170 Thn 0 Bin 22 Hari (P) + FWD RS ABDI WALUYO —. Prat a1 Satan, 9.809 Fon {NS cleanin 215 Mena TIM 4 Takara Pusat 10350, ERSPOTOEVLIEDEI Tio: (21)3144989 KRITERIA MASUK ICU (CRITERIA FOR ADMISSION OF ICU) Yai Yes (\) Tidak/ No (v) Vital Sign | a. Nadi <40 atau >150 kali’ menit . Pulse < 40 o7 >150 bead minutes v B. Tekanan darah sisiolk <80 mmig alau panuranan 20 mmHg dari tekanan daren sitolc Dasanya Systole blood pressure < 60 ming or 20 mmHg reduction of blood pressure usually systotk |e: Tekanan arlor rata-rata >120 mmHg Mean Arterial Pressure >120 malig i, Respirasi >35 kali! menit Respiration rate >35 beats/min Nilai Laboratorium . ‘a. Kadar Natrium serum <110 mEq/l. atau >170 mEq Levels of serum sodium <140mEq/L or =170mEq/L b. Kadar Kallum serum <2,0 mEqil atau 57,0 mEq/ Levels of serum potassium <2.0mEq/ or >7.0mEq/. . PaO? <0 mmHg Pa02<50 mmHg d. pH<7.4 atau>7.7 v v v wu ~ Uy , Giukosa serum > 800 mgid Serum glucose >B00mg/d {. Kalsium serum >15 mg/dl Serum calcium 15 mg/dl 9. Kadar obat atau substansi kimia dalam darah telah melebihi dosis, toksis yang menggangu hemodinamik dan status neurologis, Levels of drug or substance of the chemical in the blood has been exceed dose of toxic who disrupt haemodynamic and status neurologic : ~~ Hasil Radiologi ‘@ Pendarahan ceberal, contusio atau pendarahan subarachnoid dengan penurunan status mental Cerebral hemorrhage, contusion, or subarachnoid hemorrhage with a decrease in mental status . Diseksi corta aneurisma Aortic dissection aneurysms ECG @ Infark miokard dengan arimia kompleks, aangguan hemodnamik atau gaoal jantung Kengost# Complex myocardinal infarction with arrthyhmia, hemédynamic distrubances or congestive heart failure ‘ ®. Ventikulartaokardi atau ventricular fibril Ventricular tachycardia or ventrculr rifation c. Blok jantung komplit dengan hemodinamik tidak stabil i Complete hear block with unstable haemodynamic % NESTING ji RM/C01/105/ReV.0Pemerikasaan Fi ’@,_ Pupil anisokor pada pasien dengan penurunan kesadaran Y Pupil anisokor on the patient with the decrease of consciousness B. Luka bakar 10% luas permiKaan tubun Bum >10%of body surface © Anuria = : W Anuria : @. Obstruksi saturan napas Airway obstracon . e. Koma Coma : v {. Kejang berulang (status konvuisi) - Y 7 Conwulsion state @ Sianosis Cyanotic Vv h. Tamponade Jantung - Cardiac tomponade : . 7% Pasca pembedahan ‘Pasta pembedahan sedang Post moderate surgery VU |B. Pasca pembedahan mayor T 1 Post major surgery | | ~Kesimpulan/ Conclusion — Berdasarkan kondisiciatas maka pasien ini memenuhi inéikasi masuk IGU dengan prontas I. Under the conditions above, this pationts indicated to tread in {CU with Paty Lercnnccceon oe Alat transporf yang diperlukan brancard ( v kursi roda (_) Transport equitment needed brancard (4 whee! chair ( ) a | Jakarta, Bind OP Pendamping selama transigt dokter (y) paramedik ( ), POS ( ) gam Zoe Transfer esccarts doctor Yh paramedic () care giver ( ) ; | Tanda tangan DPJP Alat medis yang dibawa selama transfer Attending Doctor and Signature Medical equiment needed whie transfer: Tidak ( ) Ya (fenton + : cos 2 No J, Yes (“Mention (pop tetin Mates Lee, (4 Catatan ‘Mohon disi tanda cak(s) dengan lengkap ‘pleas fil tck/eheck (j to complete RM/C02/105/ ReV. 0 *