Prokalite | KISITLAMA ALTINDAKİ HASTA DEĞERLENDİRME VE TAKİP FORMU

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HB.FR.013 - KISITLAMA ALTINDAKİ HASTA DEĞERLENDİRME VE TAKİP FORMU

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Demo Hastanesi (Prokalite.Com) KISITLAMA ALTINDAKİ HASTA DEĞERLENDİRME VE TAKİP FORMU

Doküman Kodu: HB.FR.013

Yayın Tarihi: 27.11.2013

Revizyon Tarihi: 14.09.2022

Revizyon No: 1

Sayfa: Otomatik

TARİH			KISITLAMA TARİHİ			SONLANDIRMA TARİHİ
HASTANIN			KISITLAMA SAATİ			SONLANDIRMA SAATİ
ADI SOYADI			KISITLAMA TİPİ	[] TİP 1 [] TİP 2		AİLENİN BİLGİLENDİRİLMESİ	[] EVET [] HAYIR
DOSYA NO			Kısıtlama Kararını Veren Hekim			Sonlandırma Kararını Veren Hekim
CİNSİYET			Adı Soyadı İmza			Adı Soyadı İmza
YAŞ			Adı Soyadı İmza			Adı Soyadı İmza

ALTERNATİF GİRİŞİMLER			KISITLAMA NEDENİ			KISITLAMA ŞEKLİ			KISITLAMA NOTU
Konuşarak sakinleştirme	[]		Kendine zarar veriyor	[]		Üst Ekstremite	[]Sağ []Sol
Dikkatini başka yöne çekme	[]		Çevresine zarar veriyor	[]		Alt Ekstremite	[]Sağ []Sol
Mobilizasyon	[]		Aşırı ajitasyon	[]		Kol Tespit Tahtası	[]Sağ []Sol
Psikolojik destek sağlama	[]		Oryantasyon bozukluğu	[]		Parmaksız Eldiven	[]Sağ []Sol
Ek konsültasyon	[]		Tibbi tedaviye uyumsuzluk	[]		Kimyasak Kısıtlama	[]Sağ []Sol
Hasta ile iletişimi artırma	[]		Düşme tehlikesi mevcut	[]		Diğer(Açıklayınız)	[]Sağ []Sol
Diğer girişimler	[]		Diğer………………………………	[]		Kimyasakl kısıtlama var ise İlacın Adı/ Dozu/Veriliş Yolu	[]Sağ []Sol

DAVRANIŞ			Hasta, ajite ise; 30 dakikada bir, ajite değil ise; 2 saatte bir değerlendirilecek				İhtiyaç Halinde Değerlendirilecek
U- Uykulu			D - Dolaşım	1. Bozulmamış[]	2.Rengi Değişmiş []		B- Beslenme	1.Oral	2.Parenteral	3.Enteral
S- Sakin			KK- Kısıtlama Komplikasyonu 0.Yok 1.İv İnfiltrasyon 2.Bası Yarısı 3.Psikolojik Bozukluk 4.Duyu Kaybı 5.Diğer				E- Eliminasyon	1.Var	2.Yok
A- Ajite							H-Hijyen gereksinimi	1.Var	2.Yok
K- Konfüze							KS-Kısıtlama Sonlandırma	1.Evet	2.Hayır
							M-Mobilizasyon	1.Evet	2.Hayır
							O-Oksijen İhtiyacı	1.Evet	2.Hayır

Saat	Davranış	D	KK	B	E	H	KS	M	O	Değerlendiren	Yorumlar

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<table style="border-collapse:collapse; width:1292px" class=" cke_show_border" cellspacing="0"><tbody><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:16px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">TARİH</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:35px"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle; width:138px"><span style="font-size:11px"><strong><span style="color:black">KISITLAMA TARİHİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; vertical-align:middle; width:120px"><span style="font-size:15px"><span style="color:black">  </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:24px"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle; width:166px"><span style="font-size:11px"><strong><span style="color:black">SONLANDIRMA TARİHİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; vertical-align:middle; width:182px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">HASTANIN</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:138px"><span style="font-size:11px"><strong><span style="color:black">KISITLAMA SAATİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:120px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:166px"><span style="font-size:11px"><strong><span style="color:black">SONLANDIRMA SAATİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:182px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">ADI SOYADI</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:138px"><span style="font-size:11px"><strong><span style="color:black">KISITLAMA TİPİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:middle; width:120px"><span style="font-size:11px"><strong><span style="color:black"> [] TİP 1    []  TİP 2</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:166px"><span style="font-size:11px"><strong><span style="color:black">AİLENİN  BİLGİLENDİRİLMESİ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:middle; width:182px"><span style="font-size:11px"><strong><span style="color:black"> [] EVET  [] HAYIR</span></strong></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:30px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">DOSYA NO</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td colspan="2" style="border-bottom:none; border-left:1px solid black; border-right:.7px solid black; border-top:1px solid black; vertical-align:middle; width:258px"><span style="font-size:11px"><strong><span style="color:black">Kısıtlama Kararını Veren Hekim</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td colspan="2" style="border-bottom:none; border-left:1px solid black; border-right:.7px solid black; border-top:1px solid black; vertical-align:middle; width:348px"><span style="font-size:11px"><strong><span style="color:black">Sonlandırma Kararını Veren Hekim</span></strong></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">CİNSİYET</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td colspan="2" rowspan="2" style="border-bottom:.7px solid black; border-left:1px solid black; border-right:.7px solid black; border-top:none; text-align:left; vertical-align:top; width:258px"><span style="font-size:11px"><strong><span style="color:black">Adı Soyadı İmza</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td colspan="2" rowspan="2" style="border-bottom:.7px solid black; border-left:1px solid black; border-right:.7px solid black; border-top:none; text-align:left; vertical-align:top; width:348px"><span style="font-size:11px"><strong><span style="color:black">Adı Soyadı İmza</span></strong></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:60px"><span style="font-size:11px"><strong><span style="color:black">YAŞ</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:115px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr></tbody></table><table style="border-collapse:collapse; width:1292px" class=" cke_show_border" cellspacing="0"><tbody><tr><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:16px; text-align:center; vertical-align:top; width:202px"><span style="font-size:11px"><strong><span style="color:black">ALTERNATİF GİRİŞİMLER</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:9px"><br></td><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top; width:199px"><span style="font-size:11px"><strong><span style="color:black">KISITLAMA NEDENİ</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:6px"><br></td><td colspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:top; width:361px"><span style="font-size:11px"><strong><span style="color:black">KISITLAMA ŞEKLİ</span></strong></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:9px"><br></td><td colspan="2" rowspan="8" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:248px"><span style="font-size:15px"><span style="color:black">KISITLAMA NOTU</span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Konuşarak  sakinleştirme</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Kendine zarar veriyor</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Üst Ekstremite</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Dikkatini başka yöne çekme</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Çevresine zarar veriyor</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Alt Ekstremite</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; height:16px; text-align:left; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Mobilizasyon</span></strong></span></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Aşırı ajitasyon</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Kol Tespit Tahtası</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Psikolojik destek sağlama</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Oryantasyon  bozukluğu</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Parmaksız Eldiven</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; height:16px; text-align:left; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Ek konsültasyon</span></strong></span></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Tibbi tedaviye uyumsuzluk</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Kimyasak Kısıtlama</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Hasta ile iletişimi artırma</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Düşme tehlikesi mevcut</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Diğer(Açıklayınız)</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; height:25px; text-align:left; vertical-align:top"><span style="font-size:11px"><strong><span style="color:black">Diğer girişimler</span></strong></span></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:135px"><span style="font-size:11px"><strong><span style="color:black">Diğer………………………………</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle; width:288px"><span style="font-size:11px"><strong><span style="color:black">Kimyasakl kısıtlama var ise İlacın Adı/ Dozu/Veriliş Yolu</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">[]Sağ []Sol</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td></tr></tbody></table><table style="border-collapse:collapse; width:1292px" class=" cke_show_border" cellspacing="0"><tbody><tr><td colspan="2" rowspan="1" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:20px; vertical-align:bottom; width:64px"><span style="font-size:15px"><span style="color:black">DAVRANIŞ</span></span><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:8px"><br></td><td colspan="3" style="border-bottom:1px solid black; border-left:1px solid black; border-right:.7px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:494px"><span style="font-size:15px"><span style="color:black">Hasta, ajite ise; 30 dakikada bir, ajite değil ise; 2 saatte bir değerlendirilecek</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom; width:7px"><br></td><td colspan="4" style="border-bottom:1px solid black; border-left:1px solid black; border-right:.7px solid black; border-top:1px solid black; text-align:center; vertical-align:bottom; width:357px"><span style="font-size:15px"><span style="color:black">İhtiyaç Halinde Değerlendirilecek</span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:20px; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">U- Uykulu</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">              </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">D - Dolaşım</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">1. Bozulmamış[]</span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black">2.Rengi Değişmiş []</span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">B- Beslenme</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Oral</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Parenteral</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:middle; width:69px"><span style="font-size:11px"><strong><span style="color:black">3.Enteral</span></strong></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:20px; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">S- Sakin</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td colspan="3" rowspan="5" style="border-color:black; border-style:solid; border-width:1px 0.7px 0.7px 1px; vertical-align:top; width:494px"><p><span style="font-size:15px"><span style="color:black">KK- Kısıtlama Komplikasyonu       0.Yok  1.İv İnfiltrasyon  </span></span><span style="font-size:15px"><span style="color:black">2.Bası Yarısı<br>              3.Psikolojik Bozukluk<br>              4.Duyu Kaybı<br>              5.Diğer</span></span></p></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">E- Eliminasyon</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Var</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Yok</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:69px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:20px; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">A- Ajite</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">H-Hijyen  gereksinimi</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Var</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Yok</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:69px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:20px; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">K- Konfüze</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:bottom"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">KS-Kısıtlama  Sonlandırma</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Evet</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Hayır</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:69px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; height:20px; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">M-Mobilizasyon</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Evet</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Hayır</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:69px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; height:20px; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:none; border-left:none; border-right:none; border-top:none; vertical-align:bottom"><br></td><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:none; border-top:none; vertical-align:middle; width:134px"><span style="font-size:11px"><strong><span style="color:black">O-Oksijen İhtiyacı</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:64px"><span style="font-size:11px"><strong><span style="color:black">1.Evet</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:none; border-top:none; text-align:left; vertical-align:middle; width:90px"><span style="font-size:11px"><strong><span style="color:black">2.Hayır</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:69px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr></tbody></table><table style="border-collapse:collapse; width:1292px" class=" cke_show_border" cellspacing="0"><tbody><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; height:16px; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">Saat</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:47px"><span style="font-size:11px"><strong><span style="color:black">Davranış</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">D</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">KK</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">B</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">E</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">H</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">KS</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">M</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:40px"><span style="font-size:11px"><strong><span style="color:black">O</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:99px"><span style="font-size:11px"><strong><span style="color:black">Değerlendiren</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:top; width:231px"><span style="font-size:11px"><strong><span style="color:black">Yorumlar</span></strong></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr><tr><td style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; height:16px; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:47px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:40px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:99px"><span style="font-size:15px"><span style="color:black"> </span></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle; width:231px"><span style="font-size:15px"><span style="color:black"> </span></span></td></tr></tbody></table><p><br></p>