Follow Up Pasien Bu 11-05-2014
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FOLLOW UP PASIEN DI BURN UNIT 1. Identitas :Yusan, L, 36 thn, 1.67.44.20, ; BB 64kg 2. Diagnosis : Combutio grade II-III 14%ec Api listriktereduksi 13% H58,post amputasi below knee dextra H58,post amputasi below elbow dextra H49,post debridement H36, post amputasi below cubiti sinistra H7,post flap regio parietal H9 3. Tanggal :11 Mei 2014 4. Harike :66
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Transcript of Follow Up Pasien Bu 11-05-2014
FOLLOW UP PASIEN DI BURN UNIT
1. Identitas :Yusan, L, 36 thn, 1.67.44.20, ; BB 64kg2. Diagnosis : Combutio grade II-III 14%ec Api listriktereduksi 13% H58,post amputasi
below knee dextra H58,post amputasi below elbow dextra H49,post debridement H36, post amputasi below cubiti sinistra H7,post flap regio parietal H9
3. Tanggal :11 Mei 20144. Harike :66
O B Y E K T I F
Tgl 11 Mei 2014 05.00S : nyeri luka post amputasi (+)O : KU : Sedang, CMVital sign :TD: mmhgN : x/menitR : x/menitT : 0C
Assesment :Combutio grade II-III 14%ec Api listriktereduksi 13% H58,post amputasi below knee dextra H58,post amputasi below elbow dextra H49,post debridement H36, post amputasi below cubiti sinistra H7,post flap regio parietal H8
TBSA: 1,5
IWL = (25+%LB)xTBSAx24 = (25+ 14)x1,5 x24 = 1404cc/24 jamKebutuhan cairan= (1500xTBSA)+IWL= (1500x1,5)+1404= 3000 cc/ 24 jamEnteral 2654 ccParenteral 1000 ccKebutuhan protein = 2 g/kgBB / 24 jam = 128 gram
P E R K E M B A N G A N
2/5/14Hb 8,2AT 526Al 13,6Na 142 K 3,46Cl 100Alb 2,84Mg 1,95Ca 2,05
1/5/2014Hb 7,1AL 12,21AT 568Alb 2,87Na 144K 3,64Cl 101
M A S A L A H
- Nyeri- Hipoalbuminemia membaik- Anemia
Balance cairan :CM : cc/24 jam CK : cc/24 jamIWL cc/24jamBC : ccDiuresis : cc/kgBB/jamUOP 2 jam terakhir: cc
Plan :- Awasi KU/VS- Inj Ketorolac 30 mg/8 Jam(K/P)- Inj Meropenem 1gr/12jam- Inj Ranitidin 1 Amp/12 Jam- Gentamicyn zalf- Sistenol 3x1 (K/P)- Vit C 3x1- Kebutuhan cairan 3000 cc/24 jam- Keb Protein 60-120 gram/24 jam- Mobilisasi s/d jalan
FOLLOW UP PASIEN DI BURN UNIT
1. Identitas :Muhadi, L, 45 thn, 1.67.42.54, ; BB 70kg2. Diagnosis : Combutio grade II 15 %, III 7 %ec listrik H 69,Kompartemen sindrom post
escharotomy,post disartikulasi phalanx 2,3,4 manus D H57,Post Debridement H41
3. Tanggal : 11 Mei 20144. Harike : 69
O B Y E K T I F
Tgl 11 Mei 2014 05.00S : Nyeri(+), demam (-)O : KU : Sedang, CMVital sign :TD: mmhgN : x/menitR : x/menitT : 0C
Assesment :Combutio grade II 15 %, III 7 % eclistrik H 64,Kompartemen sindrom post escharotomy,post disartikulasi phalanx 2,3,4 manus D H52,Post Debridement H36
ARF membaik
TBSA: 1,81IWL = (25+%LB)xTBSAx24 = (25+ 7)x1,81 x24 = 1390cc/24 jam
Kebutuhan cairan=(1500x1,81)+ IWL= 2715+ 1390= 4105 cc/24 jamOral 3100 ccIVFD 1000cc = 42cc/jam
P E R K E M B A N G A N29/4/2014Hb 11,9AL 7,61Hmt 35,6AT 419Na 144K 4,60Cl 101AST 34ALT 62Alb 3,46Bun 7Creat 1,01
20/4/2014AL 7,5Hb 11.4AE 4,07At 484Bun 6Creat 0,87Alb 2,98Na 138K 4,03Cl 101
19/4/14Tigecycline = sensitiveHasil Mengindikasikan Multi Drug resistance
M A S A L A H- Peningkatan enzym
transaminase- Hipoalbumin membaik- Hiponatremia membaik
Balance cairan :CM : cc/24 jamCK : cc/24 jamIWL cc/24jamBC : ccDiuresis : cc/kgBB/jamUOP 2 jam terakhir: cc
Plan : Awasi KU / VS IVFD RL:KAENMg 3:Aminofluid :
1:1:1 = 42 cc/jamDiet TKTP + Ekstra PUTEL Inj. Tramadol 100mg/12 jam Sistenol 3x1 (k/p) Cetirizine 1 tab po (k/p) Rawat luka dengan burnazin Vit 3x1 Pro tutup defek
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram
FOLLOW UP PASIEN DI BURN UNIT
1. Identitas : Riyono , L, 17 th, 1 68 21 32 , BB 58 kg2. Diagnosis : Combutio grade II – III 1 % e.c Listrik H8 Post Debridement, STSG,
Escharotomy, Groin flap H13. Tanggal : 11 Mei 20144. Harike : 11
O B Y E K T I F
Tgl 11 Mei 2014 05.00S : Nyeri(+), demam (-)O : KU : Sedang , CMVital sign :TD: mmhgN : x/menitR : x/menitT : 0C
Assesment : Combutio grade II –III 1 % ec
Listrik H8, Post Debridement,STSG, Escharotomy, Groin Flap H1
TBSA: 1,8IWL = (25+%LB)xTBSAx24 = (25+ 1)x1,81 x24 = 1123,2cc/24 jam
Kebutuhan cairan=(1500x1,8)+ IWL= 2700+ 1123,2= 3823,2 cc/24 jamOral 1823,2 ccIVFD 2000cc = 83cc/jam
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram
P E R K E M B A N G A N
7/5/2014AL 9,81Hgb 13,3HCT 37,7AT 237Na 146K 4,43Cl 104TP 6,4Glob 2,1AST 24ALT 21Alb 4,3BUN 14Creat 15/5/2014AL 8,85Hgb 12,5HCT 35,3AT 230Na 147K 3,84Cl 105BUN 12Creat 0,94GOT 22GPT 222/5/14Hb 13At 227Al 9,92Na 147K 4,6Cl 105Mg 2,04Alb 4,53Ca 2,2
M A S A L A H- Luka bakar ec listrik 1%
Balance cairan :CM : cc/24 jamCK : cc/24 jamIWL cc/24jamBC : ccDiuresis : cc/kgBB/jamUOP 2 jam terakhir: cc
Plan : Awasi KU / VS Diet TKTP IVFD RL : 1000 cc/24jam Inj Cefotaxime 1gr/12 jam Inj Ranitidin 50mg/12 jam Inj Ketorolac 30mg/8 jam
FOLLOW UP PASIEN DI BURN UNIT
1. Identitas : Surono, L, 61 th, 1618131 , BB 70 kg TB 170 cm 2. Diagnosis : Combustio gr II 44 % e.c. Api H33. Tanggal :11 Mei 20144. Harike : 4
O B Y E K T I F
Tgl 11 Mei 2014 05.00S : Nyeri(+), demam (-)O : KU : Sedang , CMVital sign :TD: mmhgN : x/menitR : x/menitT : 0C
Assesment : Combutio grade II 44 % ec
Api H3
TBSA: 1,8IWL = (25+%LB)xTBSAx24 = (25+ 44)x1,8 x24 = 1656 cc/24 jam
Kebutuhan cairan=(1500x1,8)+ IWL= 2700+ 1656= 4356 cc/24 jamOral 1000 ccIVFD 3356 cc = 139,8 cc/jam
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram
P E R K E M B A N G A N
10/5/14AL 3HGB 11HCT 35AT 45Na 130K 4Cl 103Alb 1,46BUN 50Cre 1,95
7/5/14AL 16,78HGB 18HCT 50,5AT 95Na 140K 3,51Cl 103Urine RutinpH 5,5Uro NormalGlu –Pro –Bil –Blood +-Ket +-Nitrit –Leukosit –Warna Jernih
M A S A L A H- Luka bakar ec Api 44 %
Balance cairan :CM : cc/24 jamCK : cc/24 jamIWL cc/24jamBC : ccDiuresis : cc/kgBB/jamUOP 2 jam terakhir: cc
Plan : Awasi KU / VS IVFD HAES : 52,6 cc/jam Inj Ceftriaxon 1gr/12 jam Inj Ranitidin 50mg/12 jam Inj Ketorolac 30mg/8 jam Vit C 100 mg/12 jam Inpepsa syrup Cth I/8 jam Balance cairan/jam Oral : 680 cc
