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TitleAsesmen Tahap Terminal
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Page 1

RUMAH SAKIT KARYA MEDIKA II
Jl. Sultan Hasanudin No.63 Tambun – Bekasi 17510

Telp. ( 021 ) 88327514, 88324366, 88361980,70207457 Fax : ( 021 ) 88327515
E-mail : [email protected]

ASESMEN TAHAP
TERMINAL

Nama / Jenis
Kel : ...............................
TGl.
Lahir : .........................
......
No.
RM : .........................
......
Alamat : ..................
.............

Dr. yg
merawat : ............................
..
Dr.
Kosulen : .......................
.......
Dx
Medis : ......................
........


PEMERIKSAAN FISIK
1. Pernafasan :

1) Irama nafas : ……….
2) Suara nafas tambahan : ………
3) Sesak nafas : ………

4) Batuk, sputum : ………
5) Alat bantu nafas, mode, SaO2 :
…………………………………………………………………………………………………………………

2. Kardiovaskuler :
Irama jantung :
………………………………………………………………………………………………………………..
Akral :
………………………………………………………………………………………………………………..
Pulsasi :
………………………………………………………………………………………………………………..
Perdarahan :
………………………………………………………………………………………………………………...
Cvc :
………………………………………………………………………………………………………………..
Tekanan darah nadi, MAP, suhu :
…………………………………………………………………………………………………………………
Lain-lain :
…………………………………………………………………………………………………………………

3. Persyarafan :
GCS :
…………………………………………………………………………………………………………………
Kesadaran :
…………………………………………………………………………………………………………………
ICP :
…………………………………………………………………………………………………………………
Tanda-tanda peningkatan TIK :
…………………………………………………………………………………………………………………

Konjungtiva :
…………………………………………………………………………………………………………………
Lain-lain :
…………………………………………………………………………………………………………………

4. Perkemihan :
Kebersihan area genetalia :
…………………………………………………………………………………………………………………
Jumlah cairan masuk :
…………………………………………………………………………………………………………………
Buang air kecil :
………………………………………………………………………………………………………………….

Produksi urine :
…………………………………………………………………………………………………………………

5. Pencernaan :
Nafsu makan :
…………………………………………………………………………………………………………………
NGT :
…………………………………………………………………………………………………………………
Porsi makan :

mailto:[email protected]

Page 4

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Page 5

RUMAH SAKIT KARYA MEDIKA II
Jl. Sultan Hasanudin No.63 Tambun – Bekasi 17510

Telp. ( 021 ) 88327514, 88324366, 88361980,70207457 Fax : ( 021 ) 88327515
E-mail : [email protected]

Menggendong ya/tidak

PERAWATAN KRITIS

Nama / Jenis
Kel : ...............................
TGl.
Lahir : .........................
......
No.
RM : .........................
......
Alamat : ..................
.............

Dr. yg
merawat : ............................
..
Dr.
Kosulen : .......................
.......
Dx
Medis : ......................
........


PEMERIKSAAN FISIK
1. Pernafasan :

Irama nafas :
………………………………………………………………………………………………………………….

Suara nafas tambahan :
………………………………………………………………………………………………………………….

Sesak nafas :
…………………………………………………………………………………………………………………

Batuk, sputum :
…………………………………………………………………………………………………………………
Alat bantu nafas, mode, SaO2 :
…………………………………………………………………………………………………………………

2. Kardiovaskuler :
Irama jantung :
………………………………………………………………………………………………………………..
Akral :
………………………………………………………………………………………………………………..
Pulsasi :
………………………………………………………………………………………………………………..
Perdarahan :
………………………………………………………………………………………………………………...
CVC :
………………………………………………………………………………………………………………..
Tekanan darah nadi, MAP, suhu :
…………………………………………………………………………………………………………………
Lain-lain :
…………………………………………………………………………………………………………………

3. Persyarafan :
GCS :
…………………………………………………………………………………………………………………
Kesadaran :
…………………………………………………………………………………………………………………
ICP :
…………………………………………………………………………………………………………………
Tanda-tanda peningkatan TIK :
…………………………………………………………………………………………………………………

Konjungtiva :
…………………………………………………………………………………………………………………
Lain-lain :
…………………………………………………………………………………………………………………

4. Perkemihan :
Kebersihan area genetalia :
…………………………………………………………………………………………………………………
Jumlah cairan masuk :
…………………………………………………………………………………………………………………
Buang air kecil :
………………………………………………………………………………………………………………….

mailto:[email protected]

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