Nama Item |
Nilai Item |
Urutan |
Keterangan (EWS Anak) | 0 = Skor Normal (Putih) Penilaian dilakukan 12 Jam Sekali 1 - 3 = Skor Rendah (Hijau) Penilaian dilakukan 4 Jam Sekali 4 - 6 = Skor menengah (Kuning) Penilaian dilakukan 1 Jam Sekali ≥ 7 = Skor tinggi (Merah) Penilaian dilakukan 10 Menit Sekali | |
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Pencatatan Observasi EWS Anak |
Pencatatan observasi menggunakan Early Warning Score (EWS) untuk pasien dengan 0 - 16 Tahun | | EWS | Tanggal | | | | | | | | | | | | | | | | | | | 0 | 1 | 2 | 3 | Jam | | | | | | | | | | | | | | | | | | | | | | | A | | | | | | | | | | | | | | | | | | | TINGKAT KESADARAN | V | v | | | | | | | | | | | | | | | | | | P/U | | | | | | | | | | | | | | | | | | | TEKANAN DARAH (SISTOLIK) | ≥ 140 | | | | | | | | | | | | | | | | | | | 130 - 139 | 130 | | | | | | | | | | | | | | | | | | 120 - 129 | | | | | | | | | | | | | | | | | | | 90 - 119 | | | | | | | | | | | | | | | | | | | 80-89 | | | | | | | | | | | | | | | | | | | ≤ 80 | | | | | | | | | | | | | | | | | | | NADI | ≥ 150 | | | | | | | | | | | | | | | | | | | 130-149 | | | | | | | | | | | | | | | | | | | 110-129 | 110 | | | | | | | | | | | | | | | | | | 70-110 | | | | | | | | | | | | | | | | | | | 50-69 | | | | | | | | | | | | | | | | | | | ≤ 50 | | | | | | | | | | | | | | | | | | | PERNAFASAN | ≥ 50 | | | | | | | | | | | | | | | | | | | 40 - 49 | | | | | | | | | | | | | | | | | | | 30 - 39 | | | | | | | | | | | | | | | | | | | 16 - 29 | 16 | | | | | | | | | | | | | | | | | | 11 - 15 | | | | | | | | | | | | | | | | | | | ≤ 10 | | | | | | | | | | | | | | | | | | | SUHU | ≥ 39,1° | | | | | | | | | | | | | | | | | | | 38,1° | | | | | | | | | | | | | | | | | | | 37,1° - 38° | | | | | | | | | | | | | | | | | | | 36,1° 37° | 36 | | | | | | | | | | | | | | | | | | 35,1° - 36° | | | | | | | | | | | | | | | | | | | ≤35° | | | | | | | | | | | | | | | | | | | SpO2 | ≥ 94 | | | | | | | | | | | | | | | | | | | 90 - 93 | 90 | | | | | | | | | | | | | | | | | | 86 -89 | | | | | | | | | | | | | | | | | | | ≤ 85 | | | | | | | | | | | | | | | | | | | OKSIGEN | ≥ 2 L | | | | | | | | | | | | | | | | | | | ≤ 2 L | | | | | | | | | | | | | | | | | | | Tidak | tidak | | | | | | | | | | | | | | | | | | Paraf dan Nama Petugas | Gilang | | | | | | | | | | | | | | | | |
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