RM 10.

Nama Pasien : ...................................... No. RM :

Jenis Kelamin :L/P Tgl Lahir : ............................/.........Thn/Bln/Hr

Ruang / Kelas : ......................../............ Tgl Masuk : ................................. Jam : .............

RESUSITASI JANTUNG DAN PARU

Diagnosa dan Rencana Tindakan Keperawatan
Diagnosis/ indikasi dilakukan resusitasi jantung paru :
Dimulai pada pukul : .......................................................................................................................................................
Diakhiri pada pukul : ..................................................... Lama resusitasi jantung paru : ..............................................
Resusitasi jantung paru dilakukan oleh : Dokter : ................................................................................................................
Perawat : ..............................................................................................................
Dilakukan intubasi pada jam : ....................................... Ukuran ETT : ......................................... Batas : .............................
Pelaksanaan intubasi : Dokter Perawat Jenis intubasi : .....................................................................................
Pemasangan akses intra vena : ....................................... Cairan IV yang dipakai : ......................................................

Penatalaksanaan Resusitasi Jantung Paru ( Monitoring Obat-obatan, Defibrilasi dan lain-lain)

Tgl Observasi Terapi

Keterangan
Jam Nadi RR Tekanan Darah Gambaran EKG SPO2 Nama Obat Dosis Rute

DEFIBRILASI

Ritme EKG Waktu Ritme EKG Joules

1. ...................................... ...................................... ...................................... ......................................

2. ...................................... ...................................... ...................................... ......................................
3. ...................................... ...................................... ...................................... .. ....................................
4. ...................................... ...................................... ...................................... ......................................
5. ...................................... ...................................... ...................................... ......................................

Hasil Akhir Resusitasi Jantung Paru :

....................................................................................................................................................................................................
............................................................................................................................................................... .....................................
Keterangan :
Outcome resusitasi jantung paru : ICU Ruang umum Meninggal

Tulungagung, .......................................... Jam : ........

Dokter Perawat

( .....................................................) ( .....................................................)
Tanda Tangan & Nama Terang Tanda Tangan & Nama Terang