FU BU 19 September 2015.doc
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FOLLOW UP PASIEN DI BURN UNIT Identitas : Ngatmini, P, 45 thn, 1736977, 60kg Diagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+29 Tanggal : 19 September 2015 HariKe- : 49 OBJEKTIF Tgl 19 September 2015 (05.00) S : Demam (-), batuk (-), nyeri (+) berkurang, VAS = 2 O : KU sedang, CM Vital Sign : BP : 129/73 mmHg HR : 84 x/mnt RR : 18 x/mnt T : 36,7 °C MAP : 92 Assessment - Vulnus Granulosum 4% TBSA ec Combustio - Post debridement + STSG (6/8/2015) IWL = (25+5%)x1.58x24jam = 47.4x24 = 1138 cc Kebutuhan Cairan = (1500xTBSA)+IWL =(1500x1,58) + 1138 cc = 3508 cc/24 jam Kebutuhan Kalori =(25xBB)+(40x%LB) =(25x60)+(40x5) =1700 kkal/24jam PERKEMBANGAN 18.9.2015 Alb 3,8 AL 6,47 OT 18 AE 3,77 PT 29 Hb 11 BUN 13,5 Hct 32,2 Cr 0,64 AT 443 Na 136 K 3,8 Cl 101 10.9.2015 Alb 3,71 AL 8,08 BUN 14,2 AE 3,83 Creat 0,59 Hb 11,1 Na 138 HMT 32,6 K 4,1 AT 412 Cl 105 GDS 132 SGOT 20 SGPT 37 31.8.2015 Alb 3,78 AL 5,7 Hb 11,0 Hct 32,6 AT 498 27.8.2015 Alb 2,88 Na 142 K 4,15 Cl 102 AL 6,86 Hb 10.3 MASALAH Penyembuhan luka Balance Cairan : CM : 3200 cc/ 24 jam CK : 2650 cc/ 24 jam IWL : 1138 cc/ 24 jam BC : -588 cc/ 24 jam BC kumulatif : +1656 cc Diuresis: 1,84 cc/kgBB/jam UO : 450 cc/ 4 jam terakhir Plan Awasi KU/VS/BC Cefadroxil 500 mg/ 12 jam As. Mefenamat 500 mg/ 8 jam Ranitidine 150 mg/ 12 jam Phenytoin 150 mg/ 12 jam Vit B complex 1 tab/ 12 jam Asam folat 1 mg/ 12 jam
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Transcript of FU BU 19 September 2015.doc
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Ngatmini, P, 45 thn, 1736977, 60kgDiagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+29Tanggal : 19 September 2015HariKe- : 49
OBJEKTIF
Tgl 19 September 2015 (05.00)S : Demam (-), batuk (-), nyeri (+) berkurang, VAS = 2O : KU sedang, CM
Vital Sign :BP : 129/73 mmHgHR : 84 x/mntRR : 18 x/mntT : 36,7 °CMAP : 92
Assessment - Vulnus Granulosum 4% TBSA ec
Combustio- Post debridement + STSG
(6/8/2015)
IWL= (25+5%)x1.58x24jam= 47.4x24= 1138 cc
Kebutuhan Cairan= (1500xTBSA)+IWL=(1500x1,58) + 1138 cc= 3508 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x5)=1700 kkal/24jam
PERKEMBANGAN
18.9.2015Alb 3,8 AL 6,47OT 18 AE 3,77PT 29 Hb 11BUN 13,5 Hct 32,2Cr 0,64 AT 443Na 136K 3,8Cl 101
10.9.2015Alb 3,71 AL 8,08BUN 14,2 AE 3,83Creat 0,59 Hb 11,1Na 138 HMT 32,6K 4,1 AT 412Cl 105GDS 132SGOT 20SGPT 37
31.8.2015Alb 3,78 AL 5,7 Hb 11,0 Hct 32,6 AT 498
27.8.2015Alb 2,88 Na 142 K 4,15 Cl 102 AL 6,86 Hb 10.3 Hct 29.6 AT 506
24.8.2015Alb 3,61 Eri 3,5 Na 135 Hb 10,2K 3,3 Hct 29,9 Cl 101 AT 600AL 6,24
MASALAH
Penyembuhan luka
Balance Cairan :CM : 3200 cc/ 24 jamCK : 2650 cc/ 24 jamIWL : 1138 cc/ 24 jamBC : -588 cc/ 24 jamBC kumulatif : +1656 ccDiuresis: 1,84 cc/kgBB/jamUO : 450 cc/ 4 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 500 mg/ 12 jam As. Mefenamat 500 mg/ 8 jam Ranitidine 150 mg/ 12 jam Phenytoin 150 mg/ 12 jam Vit B complex 1 tab/ 12 jam Asam folat 1 mg/ 12 jam
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Sunardi, L, 56 thn, 1736605, 60 kg Diagnosis : Combustio gr II-III 25% tereduksi 20 % sisa 5% ec Api Bensin, Dispepsia, AnemiaTanggal : 19 September 2015Hari Ke- : 52
OBJEKTIF
Tgl 19 September 2015 (05.00)S : Demam (-) nyeri minimal, gatal di bagian dada dan perut berkurangVAS = 2O : KU sedang, CM
Vital Sign :BP : 130/80 mmHgHR : 72 x/mntRR : 16 x/mntT : 36,9°CMAP : 96
Assessment - Combustio gr II-III25% tereduksi
20 % sisa 5% ec Api Bensin- Dispepsia perbaikan- Anemia dlm perbaikan- Hipoalbumin dlm perbaikan
IWL= (25+%LB)xTBSAx24= (25+5)x1,62x24= 1166cc/24 jam
Kebutuhan Cairan= (1500xTBSA)+IWL= 2430 cc + 1166= 3596 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x5)=1700 kkal
PERKEMBANGAN
10.09.2015Alb 4,06 AL 10,39BUN 12,1 AE 4,25Creat 0,78 Hb 11,9SGOT 23 HMT 36,4SGPT 16 AT 553Na 139K 4,23Cl 97,1
3.09.2015AL 9,07AE 5,84 Hb 14,8Hct 43,1 AL 9,07AT 192
31.08.2015AL 9,7BUN 5,8 AE 3,3Creat 0,7 Hb 9,6Na 133 Hct 29,1K 4,4 AT 581Cl 97
30.08.2015Alb 3,33Na 133K 4,8Cl 95
MASALAH
Penyembuhan luka
Balance Cairan :CM : 2600 cc/ 24 jamCK : 1900 cc/ 24 jamIWL : 750 cc/ 24 jamBC : -50 cc/ 24 jamBC kumulatif : +3230 ccDiuresis: 1,32cc/kgBB/jamUO : 600 cc/ 8 jam terakhir
Plan Awasi KU/VS/BC Cefadroxyl 500mg/ 12 jam As. Mefenamat 500 mg/ 8 jam Ranitidine 150 mg/ 12 jam Vit. B Complex 1 tab/ 12jam
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Sukrismon, L, 17 thn, 1730334, 60 kg Diagnosis : Combustio gr II 35.5 %, gr III 14 %, SIRS, HipoalbuminemiaTanggal : 19 September 2015Hari Ke- : 24
OBJEKTIF
Tgl 19 September 2015 (05.00)S : Demam (-) nyeri (+) minimalVAS = 2O : KU sedang, CM
Vital Sign :BP : 120/70 mmHgHR : 80 x/mntRR : 18 x/mntT : 36,5 °CMAP : 87
Assessment - Combustio gr II 35.5 %, gr III 14 %
ec listrik tereduksi 22 % sisa 4,5%- SIRS membaik- Hipoalbuminemia membaik
IWL= (25+%LB)xTBSAx24= 29,5 x1,62x24= 1104 cc/24 jam
Kebutuhan Cairan= (1500xTBSA)+IWL= 2430 cc + 1104= 3534 cc/24 jam
PERKEMBANGAN
10.09.2015Alb 3,67 AL 14,22BUN 14,8 AE 4,57Creat 0,73 Hb 13,6SGOT 60 HMT 39,4SGPT 128 AT 410Na 135K 4,6Cl 99
5.09.2015Na 137K 3,3 Cl 103Cl 3,30Alb 2,95
3.09.2015Alb 3,22 Hb 11,1Na 133 Hct 32,5K 3,8 Cl 102 AT 223
2.9.2015Alb 1,86 AL 13,76GDS 71 AE 3,98Na 131,9 Hb 11,9K 3,31 Hct 33,5Cl 99 AT 179
MASALAH
Penyembuhan luka
Balance Cairan :CM : 3150 cc/ 24 jamCK : 1150 cc/ 24 jamIWL : 1104 cc/ 24 jamBC : +896 cc/ 24 jamBC kumulatif : +8158 ccDiuresis: 0,79 cc/kgBB/jamUO : 250 cc/ 4 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 500mg/ 12 jam Paracetamol 500mg/ 8 jam Ranitidine 150mg/ 8 jam
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cmDiagnosis : Combustio grade II 10%, grade III 15%Tanggal : 19 September 2015Hari Ke- : 16 (17) OBJEKTIF
Tgl 19 September 2015 (05.00)S : Nyeri (-), demam (+), diare (-), muntah(-)O : KU lemah, terintubasiBP : 114/72 mmHgHR : 84 x/ mntRR : 22 x/ mntT : 37,6 0CMAP : 86
Assessment - Combustio grade II 10%, grade III
15% ec. bara api- Anemia- Syok septik
TBSA = V21x125/3600 = 0,85
IWL = (25+%LB)xTBSAx24= (25+25)x0,85x24= 1020 Kebutuhan cairan= (1500xTBSA)+IWL=(1500x0,85)+1020= 2295 cc/24jam= 96 cc/jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x21)+(40x25)=525+1000=1525 kkal/24jam
PERKEMBANGAN
18.9.2015Alb 2,83 AL 16,74GDS 132 AE 3,32Na 136 Hb 8,7K 3,1 Hct 8,7Cl 105 AT 143Ca 2PPT 19kPPT 12,1INR 1,47APTT 34,1kAPTT 32,6
16.9.2015PO2 173PCO2 41pH 7,43BE 2,1SO2 99,5
14.9.2015Alb 2,9Na 139AL 13.51Cl 107K 4.30HB 9.2GDS 112HMT 28.9
13.9.2015Alb 2,41 AL 24,05GDS 89 Eri 2,6Na 134 Hb 6,8K 4,8 Hct 21,2Cl 99 AT 22
12.9.2015Alb 1,97 AL 35,56BUN 45,3 AE 3,02Creat 1,72 Hb 8,0SGOT 383 HMT 23,6SGPT 154 AT 88Na 136,3 PPT 30,7K 4,76 APTT 127,4Cl 101 INR 2,61Ca 1,63 D-Dimer 8430GDS 121
MASALAH
NyeriAnemia HipoalbuminemiaPenyembuhan luka
Balance Cairan :CM : 1167 cc/ 24 jam CK : 800 cc/ 24 jam IWL : 1020 cc/ 24 jam BC : -653 cc/ 24 jamBC kumulatif : -3229 ccDiuresis: 1,59 cc/kgBB/jamUO: 50 cc/ 2 jam terakhir
Plan Awasi KU/VS/BC Inj. Fentanyl 1 mcg/kgBB/jam Inj. Ranitidine 25 mg/ 12 jam Inj. Paracetamol 300 mg/ 6 jam Inj. Meropenem 850 mg/ 8 jam Inj. Fosfomycine 1 gr/12 jam Inj. Vit C 500 mg/12 jam Transfusi Albumin 20% 50 cc Transfusi FFP 150 cc Transfusi TC 250 cc KCl 3x1
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Jatmiko Agung, 1742666, 30 tahun, 80 kg, 170 cmDiagnosis : Combustio grade II 46%, grade III 5%Tanggal : 19 September 2015Hari Ke- : 4
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Radiyem, 1742945, 45 tahun, 55 Kg, 155 cmDiagnosis : Combustio grade II 29% ec Api
OBJEKTIF
Tgl 19 September 2015 (05.00)S : Nyeri (+), demam (+), diare (-), muntah(+)O : KU lemah, CMVital Sign :BP : 116/66 mmHgHR : 119 x/ mntRR : 24 x/ mnt on vent SIMV PEEP 5 cmH2O FiO2 80%T : 37,6 0CMAP : 83
Assessment - Combustio grade II 46%, grade III 5%
ec. Api bensin- Trauma inhalasi
TBSA = V80x170/3600 = 1,92
IWL = (25+%LB)xTBSAx24= (25+51)x1,92x24= 3500/24 jam
Kebutuhan cairan= (1500xTBSA)+IWL=(1500x1,92)+3500= 6380 cc/24jamEnteral: 2000cc/24 jamParenteral @line: 2200cc/24 jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x80)+(40x51)=2000+2040=4040 kkal/24jam
PERKEMBANGAN
18.9.2015AL 4,83 pH 7,43AE 3,53 PO2 46,9Hb 11 PCO2 43,6Hct 32,8 SO2 82,2AT 121 HCO3 28,3BUN 19,4 BE 3,5Cr 1,28 FiO2 0,6Alb 2,41GDS 59Na 145,7K 4,1Cl 108
17.9.2015PH 7,315PO2 45PCO2 65,6BE 4,6
17/9/2015PO2 58PCO2 58,1pH 7,317cHCO3 29.1BE 1,2
16.9.2015PO2 180,1PCO2 41pH 7,41BE 0,7Na 138,2K 4,79Cl 107
MASALAH
Perbaikan KUNyeriDemamHipoalbuminSIRS
Balance Cairan :CM : 3245 cc/ 24 jam CK : 2100 cc/ 24 jam IWL : 3480 cc/ 24 jam BC : -2335 cc/ 24 jamBC kumulatif : -4176 ccDiuresis: 1,02 cc/kgBB/jamUO: 160 cc/1 jam terakhir
Plan Awasi KU/VS/BC Inj. Fentanyl 2 mcg/ kg/jam Inj. Vit C 1 amp/ 12 jam Inj. Meropenem 1gr/12 jam Inj. Ranitidine 50 mg/12 jam Inj. Paracetamol 1 gr/8 jam
Tanggal : 19 September 2015Hari Ke- : 1
OBJEKTIF
Tgl 18 September 2015 (05.00)S : Nyeri (+), demam (+), diare (-), muntah(-)O : KU lemah, CMVital Sign :BP : 132/75 mmHgHR : 84 x/ mntRR : 20 x/ mntT : 37,2 0CMAP : 94
Assessment - Combustio grade II 29% ec Api
TBSA = V55x155/3600 = 2,53
IWL = (25+%LB)xTBSAx24= (25+29)x1,5x24= 1944/24 jam= 81 cc/jam
Kebutuhan cairan= (1500xTBSA) + IWL= (1500x1,5) + 1944= 2250 + 1944= 4194 cc/24 jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x55)+(40x29)=1375 + 1160=2535 kkal/24jam
PERKEMBANGAN
17/8/2015AL 18,05AE 4,83 Hb 14,5Hct 42,6 AT 416Alb 3,37BUN 5,1Cr 0,55Na 137 K 3,55 Cl 107
MASALAH
Maintanance cairanNyeriPenyembuhan luka
Balance Cairan :CM : 7816 cc/ 24 jam CK : 4890 cc/ 24 jam IWL : 1215 cc/ 24 jam BC : +1711 cc/ 24 jamBC kumulatif : +1891 ccDiuresis: 3,7 cc/kgBB/jamUO: 510 cc/ 2 jam terakhir
Plan Awasi KU/VS/BC Inj. Fentanyl 1 mcg/kgBB/jam Inj. Ketorolac 30 mg/8 jam Inj. Vit C 1 amp/ 12 jam Inj Ranitidine 30 mg/12 jam
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