Form Dokumentasi Intake dan Output
Tanggal Diperiksa :_____________________
Nama : ............................................................
Usia : ............................................................
Asal Instansi : ............................................................
Berat Badan : ............................................................
Suhu Tubuh : ............................................................
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INTAKE
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OUTPUT
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Waktu
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Per Oral / Naso Gastric
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Jumlah (cc)
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Urine
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Feses
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Stool/Drainase
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Muntah
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Lain-Lain
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07.00
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08.00
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09.00
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10.00
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11.00
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12.00
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13.00
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14.00
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15.00
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16.00
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17.00
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18.00
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19.00
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20.00
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21.00
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22.00
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23.00
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24.00
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01.00
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02.00
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03.00
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04.00
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05.00
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06.00
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Total
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||||||
Perhitungan Balance Cairan :
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Intake
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Metabolisme air
(AM)
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Total Intake
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Output
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IWL
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Total Output
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Total Balance Cairan
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Kesimpulan
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Analisa Proses Kegiatan /
Evaluasi Diri
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Signs/Symptoms of Dehydration noted
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Lab Results
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ÿ
Mukosa bibir kering
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ÿ
BUN/Creatine ratio
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Nadi cepat
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ÿ
Serum Sodium
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ÿ
Konsentrasi Urine pekat
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ÿ
Hematocrit
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ÿ
Penurunan Haluaran (output)
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ÿ
Urine – specific gravity
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ÿ
Mata cekung
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ÿ
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ÿ
Kelemahan otot
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ÿ
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Pontianak, November 2016
Pasien Pemeriksa
(...............................................) (............................................)
NIP/NIM. NIM.
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