Form Px Peny Menular & Immunosuppressed.docx

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ASESMEN PASIEN KHUSUS PENYAKIT MENULAR DAN IMMUNOSUPPRESSED

Asesmen tanggal Tanggal MRS

: ....../......../............... : ....../........./...............

Nama Tanggal lahir No. RM

Pukul : .................... Ruang Rawat : ….

: ……………..…..…….…. : …………………...….……. : ……………………….….

Nama Petugas : ..................................

A. PENYAKIT MENULAR 1. 2. 3. 4.

Diagnosis : ............................................................................................................................................................ Ditegakkan :  baru  lama, sejak : ……………………………. Pasien mengetahui penyakit saat ini :  Tahu  Tidak Sumber informasi penyakit diperoleh dari :  Dokter  Perawat  Keluarga  Lain – lain : ............................................................................................ 5. Menerima informasi jangka waktu pengobatan :  Ya, ............................ minggu/ bulan/tahun  Tidak 6. Melakukan pemeriksaan rutin :  Tidak  Ya, di ...................................................................................... 7. Cara Penularan :  Airbone  Droplet  Kontak Langsung  Cairan Tubuh 8. Dirawat di ruang isolasi bertekanan negative :  Ya  Tidak  Kohorting  Ruang tersendiri  Lain – lain : ........................................................ Jika penuh dirujuk ke : ........................................................................................................................................................ 9. Penggunaan Alat Pelindung Diri :  Ya  Tidak Jika Ya :  Masker  sarung tangan  Baju  scort  sepatu boot  kaca mata gogle  Lain – lain : ................................................................................... 10. Penyakit Penyerta :  Ya, ...........................................................................................................................................  Tidak

B.

PENYAKIT PENURUNAN DAN DAYA TAHAN TUBUH (IMMUNOSUPRESSED) 1. 2. 3. 4. 5. 6. 7.

8.

Diagnosis : .................................................................................................................. ..................................... Ditegakkan :  baru  lama, sejak : …………………………………………………………………………..…. Pasien mengetahui penyakit saat ini :  Tahu  Tidak Sumber informasi penyakit diperoleh dari :  Dokter  Perawat  Keluarga  Lain – lain : ....................................................................................... Menerima informasi jangka waktu pengobatan :  Ya, ......................., minggu/ bulan/tahun  Tidak Melakukan pemeriksaan rutin :  Tidak  Ya, di .......................................................................................... Dirawat terpisah/ sendiri :  Ya, di…………………………………………………………………………………………………………………….  Tidak.  Dirujuk : ......................................................................................................................................................... Penyakit Penyerta :  Ya, ………………….………………………………………………………………...……….  Tidak

C. ANALISA MASALAH : ........................................................................................................................................... ....................................................................................................................................................................................... D. TINDAKAN : ............................................................................................................................................................. ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... .......................................................................................................................................................................................

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