pelan rawatan peribadi · 2014. 2. 28. · nombor telefon hospital/klinik: _____ tarikh mula...

PELAN RAWATAN PERIBADI

Personal treatment plan malay.indd 1 16/9/2556 16:46:17

Nama pesakit: _________________________________________________

Nombor ID pesakit: _____________________________________________

Nombor telefon: ________________________________________________

Hospital: ______________________________________________________

Untuk kes kecemasan, sila maklumkan (nama) ________________________

di talian _______________________________________________________

Nombor telefon hospital/klinik: _____________________________________

Tarikh mula rawatan PEG-interferon dan ribavirin: _______________ Dos PEG-interferon anda:Dos Permulaan Jururawat akan menandakan bulat pada kekuatan dos PEG-interferon:

Isipadu suntikan PEG-interferon mingguan anda ialah: ____________mL

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Pelarasan Dos 1 (Tarikh: ______________________________) Jururawat akan menandakan bulat pada kekuatan dos PEG-interferon:


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Dos ribavirin anda: Setiap pagi Setiap petangJururawat akan menandakan bulat pada dos ribavirin:

Dos Permulaan

Pelarasan Dos 1, Tarikh: ____________


-0.2 --0.3 - -0.4 - -0.5

-0.2 --0.3 - -0.4 - -0.5

-0.2 --0.3 - -0.4 - -0.5

50 mcg 80 mcg 120 mcg 150 mcg




Nama pesakit: _________________________________________________

Nombor ID pesakit: _____________________________________________

Nombor telefon: ________________________________________________

Hospital: ______________________________________________________

Untuk kes kecemasan, sila maklumkan (nama) ________________________

di talian _______________________________________________________

Nombor telefon hospital/klinik: _____________________________________

Tarikh mula rawatan PEG-interferon dan ribavirin: _______________ Dos PEG-interferon anda:Dos Permulaan Jururawat akan menandakan bulat pada kekuatan dos PEG-interferon:


____________________________________________________________________________



____________________________________________________________________________



____________________________________________________________________________

Dos ribavirin anda: Setiap pagi Setiap petangJururawat akan menandakan bulat pada dos ribavirin:

Dos Permulaan



-0.2 --0.3 - -0.4 - -0.5

-0.2 --0.3 - -0.4 - -0.5

-0.2 --0.3 - -0.4 - -0.5





PELAN dan REKOD Suntikan PEG-interferon September 2013 Februari 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 2 3 4 5 6 7 8 15 16 17 18 19 20 21 9 10 11 12 13 14 15 22 23 24 25 26 27 28 16 17 18 19 20 21 22 29 30 23 24 25 26 27 28

Oktober 2013 Mac 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 1 6 7 8 9 10 11 12 2 3 4 5 6 7 8 13 14 15 16 17 18 19 9 10 11 12 13 14 15 20 21 22 23 24 25 26 16 17 18 19 20 21 22 27 28 29 30 31 23 24 25 26 27 28 29 30 31

November 2013 April 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 1 2 3 4 5 3 4 5 6 7 8 9 6 7 8 9 10 11 12 10 11 12 13 14 15 16 13 14 15 16 17 18 19 17 18 19 20 21 22 23 20 21 22 23 24 25 26 24 25 26 27 28 29 30 27 28 29 30

Disember 2013 Mei 2014


Januari 2014 Jun 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 1 2 3 4 5 6 7 5 6 7 8 9 10 11 8 9 10 11 12 13 14 12 13 14 15 16 17 18 15 16 17 18 19 20 21 19 20 21 22 23 24 25 22 23 24 25 26 27 28 26 27 28 29 30 31 29 30

Nota• Staf Klinik: bulatkan (O) pada hari suntikan • Pesakit: tandakan pangkah (X) pada tarikh suntikan

PELAN dan REKOD Suntikan PEG-interferon Julai 2014 Disember 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 1 2 3 4 5 6 6 7 8 9 10 11 12 7 8 9 10 11 12 13

13 14 15 16 17 18 19 14 15 16 17 18 19 20 20 21 22 23 24 25 26 21 22 23 24 25 26 27 27 28 29 30 31 28 29 30 31

Ogos 2014 Januari 2015

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 1 2 3 3 4 5 6 7 8 9 4 5 6 7 8 9 10

10 11 12 13 14 15 16 11 12 13 14 15 16 17 17 18 19 20 21 22 23 18 19 20 21 22 23 24 24 25 26 27 28 29 30 25 26 27 28 29 30 31 31

September 2014 Februari 2015

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 1 2 3 4 5 6 7 7 8 9 10 11 12 13 8 9 10 11 12 13 14

14 15 16 17 18 19 20 15 16 17 18 19 20 21 21 22 23 24 25 26 27 22 23 24 25 26 27 28 28 29 30



12 13 14 15 16 17 18 15 16 17 18 19 20 21 19 20 21 22 23 24 25 22 23 24 25 26 27 28 26 27 28 29 30 31 29 30 31


Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 1 2 3 4 2 3 4 5 6 7 8 5 6 7 8 9 10 11 9 10 11 12 13 14 15 12 13 14 15 16 17 18

16 17 18 19 20 21 22 19 20 21 22 23 24 25 23 24 25 26 27 28 29 26 27 28 29 30 30


PELAN dan REKOD Suntikan PEG-interferon September 2013 Februari 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 2 3 4 5 6 7 8

15 16 17 18 19 20 21 9 10 11 12 13 14 15 22 23 24 25 26 27 28 16 17 18 19 20 21 22 29 30 23 24 25 26 27 28


Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 1 6 7 8 9 10 11 12 2 3 4 5 6 7 8

13 14 15 16 17 18 19 9 10 11 12 13 14 15 20 21 22 23 24 25 26 16 17 18 19 20 21 22 27 28 29 30 31 23 24 25 26 27 28 29 30 31


Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 1 2 3 4 5 3 4 5 6 7 8 9 6 7 8 9 10 11 12

10 11 12 13 14 15 16 13 14 15 16 17 18 19 17 18 19 20 21 22 23 20 21 22 23 24 25 26 24 25 26 27 28 29 30 27 28 29 30

Disember 2013 Mei 2014

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 1 2 3 8 9 10 11 12 13 14 4 5 6 7 8 9 10

15 16 17 18 19 20 21 11 12 13 14 15 16 17 22 23 24 25 26 27 28 18 19 20 21 22 23 24 29 30 31 25 26 27 28 29 30 31

Januari 2014 Jun 2014


12 13 14 15 16 17 18 15 16 17 18 19 20 21 19 20 21 22 23 24 25 22 23 24 25 26 27 28 26 27 28 29 30 31 29 30

Nota• Staf Klinik: bulatkan (O) pada hari suntikan • Pesakit: tandakan pangkah (X) pada tarikh suntikan

PELAN dan REKOD Suntikan PEG-interferon Julai 2014 Disember 2014


Ogos 2014 Januari 2015


September 2014 Februari 2015

Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 1 2 3 4 5 6 7 7 8 9 10 11 12 13 8 9 10 11 12 13 14 14 15 16 17 18 19 20 15 16 17 18 19 20 21 21 22 23 24 25 26 27 22 23 24 25 26 27 28 28 29 30




Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat 1 1 2 3 4 2 3 4 5 6 7 8 5 6 7 8 9 10 11 9 10 11 12 13 14 15 12 13 14 15 16 17 18 16 17 18 19 20 21 22 19 20 21 22 23 24 25 23 24 25 26 27 28 29 26 27 28 29 30 30


Jadual Temujanji

Lawatan# Tarikh Masa Butiran Lawatan

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2

3

4

5

6

7

8

9

10

11

12

13

14

15

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17

18

Nota kepada pesakit: Sila bawa yang berikut ke klinik untuk setiap lawatan: 1) buku ini, 2) ubatan yang tidak digunakan, 3) kotak beku bersama pek-pek ais

Arahan: Rekodkan di sini mana-mana dos yang tertinggal, masalah dengan ubatan dan sebarang masalah perubatan, psikologikal atau masalah lain yang anda mungkin hadapi, sama ada anda merasakan masalah itu berkaitan ataupun tidak dengan ubatan kajian. Sila senaraikan ubatan lain yang tidak ada kaitan dengan kajian yang anda ambil, seperti ubat pencegah kehamilan, herba, vitamin dan sebagainya.

Nota

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PERGI KE KLINIK ATAUPUN BILIK KECEMASAN DENGAN SEGERA SEKIRANYA ANDA MENGALAMI:

Sesak nafas

Sakit dada

Warna air kencing pekat

Kekeliruan

Bengkak keliling buku lali atau perut

Penurunan berat badan secara mendadak

Gambaran untuk mencederakan diri sendiri atau orang lain

HUBUNGI KLINIK DENGAN SEGERA SEKIRANYA:

Anda terasa sedih sepanjang hari, hampir setiap hari

Anda hamil ataupun pasangan anda hamil

Anda terlebih ambil PEG-interferon atau ribavirin

SITUASI KECEMASAN


pelan rawatan peribadi · 2014. 2. 28. · nombor telefon hospital/klinik: _____ tarikh mula...

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