Form Trombolitik [PDF]

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Check-List fibrinolitik RSBT Pangkalpinang



Langkah



Apakah pasien mengalami rasa tidak enak di dada lebih dari 15 menit dan kurang dari 12 jam



1



YA



TIDAK



Apakah EKG menunjukkan STEMI atau LBBB baru/tampaknya baru ?



YA



TIDAK



Apakah ada kontraindikasi absolut untuk fibrinolisis ?



Langkah 2



STOP



Jika SALAH SATU dari berikut ini ditandai YA. Fibrinolisis dikontraindikasikan



Riwayat penyakit sistem saraf pusat struktural



YA



TIDAK



Riwayat trauma tertutup signifikan pada kepala/ wajah dalam



YA



TIDAK



Stroke ischemic > 3 jam atau < 3 bulan



YA



TIDAK



Curiga Diseksi Aorta



YA



TIDAK



Riwayat perdarahan intrakanial kapanpun



YA



TIDAK



Perdarahan Aktif (tidak termasuk melena)



YA



TIDAK



Diketahui memiliki keganasan intracanial



YA



TIDAK



3 bulan terakhir



Formulir Tindakan Observasi Trombolitik RSBT Pangkalpinang Nama Pasien



: ....................................



Diagnosa



: ....................................



dr. Penanggung Jawab : .................................... Perawat Pelaksana



: ....................................



Tanggal



: ....................................



Jam



Ket N RR



TD SpO2 MAP EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ............................................... TD N SpO2 MAP RR EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ............................................... TD N SpO2 MAP RR EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ...............................................



Paraf



Jam



Ket N RR



TD SpO2 MAP EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ............................................... TD N SpO2 MAP RR EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ............................................... TD N SpO2 MAP RR EKG Keluhan : .............................................. .............................................. .............................................. .............................................. .............................................. Tindakan : ............................................... ............................................... ............................................... ............................................... ...............................................



Paraf