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PEMANTAUAN KEPATUHAN BUNDEL PENCEGAHAN VENTILATOR ASSOCIATED PNEUMONIA
RSUD ………………………………
Tanggal : ............................................................
Nomor RM : .......................................................................
Petugas
Hari/tgl pemasangan ventilator
Shift P S M P S M P S M P S M P S M P S M P S M P S M P S M
Hand Hygiene
Oral Hygiene dengan betadine

1% atau Chlorhexidine 0,12%
(coret bila tidak dilakukan)
Ganti ET tiap 14 hari
Suction closed type

Elevasi kepala 30-45 derajat
Pemantauan harian untuk
ekstubasi dan libur sedasi
Terapi profilaksis ulkus
peptikum
Terapi profilaksis trombosis
vena profuna
Fisioterapi
Alih Baring
Observer/perawat jaga
KOMUNIKASI SBAR
HARI : TANGGAL : BULAN : TAHUN
IDENTITAS PASIEN PAGI SORE MALAM

Nama Pasien : S : ........................................................................ S : ........................................................................ S : ........................................................................
Tgl Lahir : ....................................................................... ....................................................................... .......................................................................
No RM : ....................................................................... ....................................................................... .......................................................................
Tanggal Masuk : ....................................................................... ....................................................................... .......................................................................
DPJP : B : Kesadaran : ...... E : ....... M : ....... V : ..... B : Kesadaran : ...... E : ....... M : ....... V : ..... B : Kesadaran : ...... E : ....... M : ....... V : .....
Ruang Rawat : ....................................................................... ....................................................................... .......................................................................
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A : DX MEDIS : ................................................. A : DX MEDIS : ................................................. A : DX MEDIS : .................................................

DX KEP : ................................................ DX KEP : ................................................ DX KEP : ................................................
1. ............................................................... 1. ............................................................... 1. ...............................................................
2. ................................................................ 2. ................................................................ 2. ................................................................
3. ................................................................. 3. ................................................................. 3. .................................................................
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R : 1. ................................................................... R : 1. ................................................................... R : 1. ...................................................................
2. ................................................................... 2. ................................................................... 2. ...................................................................
3. ................................................................... 3. ................................................................... 3. ...................................................................
4. ................................................................... 4. ................................................................... 4. ...................................................................
5. ................................................................... 5. ................................................................... 5. ...................................................................
6. ................................................................... 6. ................................................................... 6. ...................................................................
Nama tanda tangan Pemberi operan : ..................... ....................... Pemberi operan : ..................... ....................... Pemberi operan : ..................... .......................
Nama tanda tangan Penerima operan : ..................... ....................... Penerima operan : ..................... ....................... Penerima operan : ..................... .......................

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PEMANTAUAN KEPATUHAN BUNDEL PENCEGAHAN VENTILATOR ASSOCIATED PNEUMONIA

Oral Hygiene dengan betadine

Ganti ET tiap 14 hari

Suction closed type

HARI : TANGGAL : BULAN : TAHUN

IDENTITAS PASIEN PAGI SORE MALAM

A : DX MEDIS : ................................................. A : DX MEDIS : ................................................. A : DX MEDIS : .................................................

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