FU BU 6 Oktober 2015
9
FOLLOW UP PASIEN DI BURN UNIT Identitas : Ngatmini, P, 45 thn, 1736977, 60kg Diagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+41 post release kontraktur, STSG, FTSG H+10 Tanggal : 6 Oktober 2015 HariKe- : 67 OBJEKTIF Tgl 6 Oktober 2015 (05.00) S : Demam (-), kejang (-), nyeri (+) berkurang, VAS = 2-3 O : KU sedang, CM Vital Sign : BP : 130/70mmHg HR : 88x/mnt RR : 16x/mnt T : 36,5°C MAP : 90 Assessment - Vulnus Granulosum 4% TBSA ec Combustio - Post debridement + STSG (6/8/2015) - Post release kontraktur + STSG +FTSG (25/9/2015) IWL = (25+4%)x1.58x24jam = 47.4x24 = 1100cc Kebutuhan Cairan = (1500xTBSA)+IWL =(1500x1,58) + 1138 cc = 3508 cc/24 jam Kebutuhan Kalori =(25xBB)+(40x%LB) =(25x60)+(40x4) =1660 kkal/24jam PERKEMBANGAN 5.10.2015 Alb 3,8 AL 5,88 OT 33 AE 4,13 PT 68 Hb 12 Na 140 Ht 34,9 K 4,2 AT 497 Cl 103 1.10.2015 Alb 3,77 AL 6,62 BUN 7,2 AE 3,89 Cre 0,65 HB 11,2 GDS 117 Ht 33,1 Na 138 AT 450 K 4,4 Cl 105 28.9.2015 Hb 10,1 AE 3.46 AL 8,97 AT 344 HCT 29,6 Alb 3,22 GDS 81 Na 136 K 3.2 Cl 103 26.9.2015 Hb 10,3 AE 3.49 AL 8,4 AT 385 HCT 29,9 MASALAH Penyembuhan luka Balance Cairan : CM : 2750 cc/24 jam CK : 1650 cc/24 jam IWL : 1100 cc/24 jam BC : 0 cc/24 jam BC kumulatif : +250 cc Diuresis: 1,15 cc/kgBB/jam UO : 250 cc/5 jam terakhir Plan Awasi KU/VS/BC Cefadroxil 500mg/12jam Asam Mefenamat 500mg/8jam Ranitidin 150mg/12jam/po Phenytoin 200mg/12 jam Acarbose 50 mg/ 8 jam Asam folat 1 mg/ 12 jam Vit. B complex 1 tab/12 jam
-
Upload
yovan-prakosa -
Category
Documents
-
view
220 -
download
0
description
Joss
Transcript of FU BU 6 Oktober 2015
FOLLOW UP PASIEN DI BURN UNITIdentitas : Ngatmini, P, 45 thn, 1736977, 60kgDiagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+41 post release kontraktur, STSG,
FTSG H+10Tanggal : 6 Oktober 2015HariKe- : 67
OBJEKTIF
Tgl 6 Oktober 2015 (05.00)S : Demam (-), kejang (-), nyeri (+) berkurang, VAS = 2-3O : KU sedang, CM
Vital Sign :BP : 130/70mmHgHR : 88x/mntRR : 16x/mntT : 36,5°CMAP : 90
Assessment- Vulnus Granulosum 4% TBSA ec
Combustio- Post debridement + STSG
(6/8/2015)- Post release kontraktur + STSG
+FTSG (25/9/2015)
IWL= (25+4%)x1.58x24jam= 47.4x24= 1100cc
Kebutuhan Cairan= (1500xTBSA)+IWL=(1500x1,58) + 1138 cc= 3508 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x4)=1660 kkal/24jam
PERKEMBANGAN
5.10.2015Alb 3,8 AL 5,88OT 33 AE 4,13PT 68 Hb 12Na 140 Ht 34,9K 4,2 AT 497Cl 103
1.10.2015Alb 3,77 AL 6,62BUN 7,2 AE 3,89Cre 0,65 HB 11,2GDS 117 Ht 33,1Na 138 AT 450K 4,4Cl 105
28.9.2015Hb 10,1 AE 3.46AL 8,97 AT 344HCT 29,6Alb 3,22GDS 81Na 136 K 3.2Cl 103
26.9.2015Hb 10,3 AE 3.49AL 8,4 AT 385HCT 29,9Alb 3,03GDS 231Na 135 K 3.6Cl 103
24.9.2015Hb 11.3 AE 3.87AL 7.31 AT 406HCT 33 PPT 13.8APTT 25.4 INR 1.0Alb 3,54 BUN 11.6Crea 0.49 GDS 171Na 137 K 3.9Cl 104
MASALAH
Penyembuhan luka
Balance Cairan :CM : 2750 cc/24 jamCK : 1650 cc/24 jamIWL : 1100 cc/24 jamBC : 0 cc/24 jamBC kumulatif : +250 ccDiuresis: 1,15 cc/kgBB/jamUO : 250 cc/5 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 500mg/12jam Asam Mefenamat 500mg/8jam Ranitidin 150mg/12jam/po Phenytoin 200mg/12 jam Acarbose 50 mg/ 8 jam Asam folat 1 mg/ 12 jam Vit. B complex 1 tab/12 jam
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Asep Sulistyo, L, 17 thn, 1744725, 50 kgDiagnosis : Combustio gr II 24% ec listrikTanggal : 6 Oktober 2015Hari Ke- : 4
OBJEKTIF
Tgl 6 Oktober 2015 (05.00)S : Demam (-), nyeri (+)O : KU sedang, CM
Vital Sign :BP : 118/52 mmHgHR : 92 x/mntRR : 16 x/mntT : 38,1°CMAP : 74
Assessment- Combustio gr II 24% ec listrik
IWL= (25+%LB)xTBSAx24= (25+24)x1,5x24= 1764cc/24 jam
Kebutuhan Cairan= (1500xTBSA) + IWL= (1500x1,5) + 1764 cc= 4014 cc/24 jam Saturasi:Jari 1 99%Jari 2 98%Jari 3 98%Jari 4 98%Jari 5 95%0
PERKEMBANGAN
05/10/2015BUN 6,5Cr 0,68
04/10/2105Alb 3,29GDS 123CK 3569CKMB 161Na 138K 4,20Cl 106Ca 2,06AL 15,31Eri 4,81Hb 14,0Hct 41,8AT 363CRP 33PCT 0,51
02/10/2015Alb 3,64SGOT 82,0SGPT 19,0BUN 6,5Cr 0,65GDS 135Na 138K3,9CL106AL 19,84AT 382AE 4,74Hb14
MASALAH
Luka bakar listrik
Balance Cairan :CM : 8429 cc/24jamCK : 5140 cc/24 jamIWL : 1764 cc/24 jamBC : +1525 cc/24 jamBC kumulatif : -544 ccDiuresis: 4,28 cc/kgBB/jamUO : 550 cc/2 jam terakhir
Plan Awasi KU/VS/BC Inj. Ranitidine 50 mg/ 12 jam Inj. Ketorolac 30mg/8jam Inj. Paracetamol 750mg/8 jam Propanolol 10 mg/6 jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cmDiagnosis : Combustio grade II 10%, grade III 15%Tanggal : 6 Oktober 2015Hari Ke- : 33
OBJEKTIF
Tgl 6 Oktober 2015 (05.00)S : Nyeri (-), demam (-), diare (-)O : KU sedang, cm
Vital SignBP : 114/71mmHgHR : 116 x/mntRR : 23 x/mntT : 38,30CMAP : 85
Manus Dextra, saturasi:I = 100%II = 98%III= 97%IV = 97%V = 97%
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= 2295cc/24jam= 96 cc/jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x21)+(40x25)=525+1000=1525 kkal/24jam
PERKEMBANGAN
5.10.2015Alb 3,13 AL 16,79BUN 9,4 AE 3,55Cr 0,25 Hb 10,2Na 137 Ht 29,8K 3,9 AT 345Cl 104 CRP 20
4.10.2015Urinalisis:Glukosa –Protein +Bilirubin –Urobilinogen 3+pH 7,0Blood 3+Keton 1+Sedimen:Eri 12455,6Leuko 39,0Bekteri 47,3
1.10.2015Alb 3,14 AL 10,8GDS 106 AE 3,51NA 139,5 HB 9,9K 3,91 HCT 30Cl 105 AT 205
29.9.2015Alb 2,88AL 12,15Eri 3,65Hb 10,4Hct 29,9AT 226
28.9.2015Hb 10,6AE 3,74AL 14,45 AT 333HCT 31,5Alb 2,36GDS 100Na 133 K 4,3Cl 102
MASALAH
NyeriAnemiaHipoalbuminemiaPenyembuhan luka
Balance Cairan :CM : 2201 cc/24 jamCK : 1660 cc/24 jamIWL : 1020 cc/ 24jamBC : -475 cc/24 jamBC : -1529 ccDiuresis: 1,98 cc/kgBB/jamUO: 110 cc/2 jam terakhir
Plan Awasi KU/VS/BC Inj. Imipenem 500mg/6jam Inj. Mikamin 80mg/24 jam Inj. Amikasin 500 mg/24 jam Inj. Paracetamol 300 mg/6 jam RF 2 ml/jam AA 10% 9ml/jam Chloramphenicol zalf 2 dd ue Propanolol 4,5 mg/8 jam Zinc 20mg/24 jam Kapsul NaCl 500mg/8 jam Vip Albumin 1 tab/ 8 jam Cetirizine 5 mg/12 jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Radiyem, 1742945, 45 tahun, 55 Kg, 155 cmDiagnosis : Combustio grade II 29% ec Api tereduksi 26% sisa 3 %Tanggal : 6 Oktober 2015Hari Ke- : 17
OBJEKTIF
Tgl 6 Oktober 2015 (05.00)S : Nyeri (+), demam (-)O : KU sedang, CM
Vital Sign :BP : 110/70 mmHgHR : 92 x/mntRR : 18 x/mntT : 37,2 CMAP : 83
Assessment- Combustio grade II 29% ec Api
tereduksi 26% sisa 3 %
TBSA= V55x155/3600 = 1,5
IWL= (25+%LB)xTBSAx24= (25+13)x1,5x24= 1368/24 jam= 57 cc/jam
Kebutuhan cairan= (1500xTBSA) + IWL= (1500x1,5) + 1368= 2250 + 1368= 3618 cc/24 jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x55)+(40x13)=1375 +520=1895 kkal/24jam
PERKEMBANGAN
5.10.2015Alb 3,49 Hb 12,6Na 139 Ht 38,9K 4,5 AT 755Cl 100AL 11,84AE 4,39
1.10.2015Prot Tot 7,62Alb 3,35 AL 10,9BUN 13,6 Ae 4,23Cre 0,54 HB 12,2Na 136 HCT 37,1K 4,8 AT 674Cl 101
28.9.2015Hb 11AE 3,81AL 15,88 AT 443HCT 32,6Alb 3,15Na 131 K 4,3Cl 99
26.9.2015Alb 3,11 Al 13,8Hb 11,3Hct 3,2At 372Na 134K 4,2Cl 103
25.9.2015Alb 2,82 Al 16,09BUN 11 Hb 10,6Crea 0,41 Hct 32,1GDS 131 At 332Na 135K 3,8Cl 102
MASALAH
NyeriPenyembuhan luka
Balance Cairan :CM : 3550 cc/24 jamCK : 1500 cc/24 jamIWL : 1368 cc/ 24 jamBC : +682 cc/24 jamBC kumulatif : - 254 ccDiuresis: 1,14 cc/kgBB/jamUO: 350 cc/5 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 2X500 mg As Mefenamat 3X500mg Ranitidin 2X150mg B Complex 2X1tab
FOLLOW UP PASIEN DI BURN UNITIdentitas : Izzatul Jannah, 00732175, 6 tahun, 25 Kg, 120 cmDiagnosis : Combustio grade II 22% ec air panasTanggal : 6 Oktober 2015Hari Ke- : 9
OBJEKTIF
Tgl 6 Oktober 2015 (05.00)S : Nyeri (+), demam (+)O : KU sedang, CM
Vital Sign :BP : 100/60 mmHgHR : 118 x/mntRR : 24x/mntT : 36,3oCMAP : 73
AssessmentCombustio grade II 22% ec air panas
TBSA= V25x120/3600 = 0,91
IWL= (25+%LB)xTBSAx24= (25+22)x 0,91 x24= 1026,48 /24 jam= 42,77 cc/jam
Kebutuhan cairan= (1500xTBSA) + IWL= (1500x 0,91) + 1026,48= 1365 + 1026,48= 2391,48 cc/24 jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25 x 25)+(40 x 22)= 625 + 880= 1505 kkal/24jam
PERKEMBANGAN
3.10.2015Alb 3,1 GDS 110Na 140 K 2,9Cl 109 Ca 2,1AL 10,6 AE 3,89HB 10,3 HT 30AT 124 Netr 7,74
30.9.2015Alb 2,9 K 4,38GDS 105 Cl 106Na 137 Ca 2,02
29.9.2015GDS 58 AL 14,14Na 136 Hb 11K 3,2 Eri 4,14Cl 107 Hct 32AT 402
28.9.2015Hb 10,6 AE 3.91AL 15,85AT 496HCT 31,3Alb 2,37GDS 419Na 130 K8,3Cl 101PO2 155,8PCO2 39,1pH7,27SO2 98,9cHCO3 17,5BE-8,3AaDO2 47,5
27.9.2015Alb 3,04 Hb 13,1SGOT 21 HMT 39,2SGPT 22 AT 344BUN 2,5 PPT 15,5Creat 0,41 Kontrol PPT 11,3GDS 123 APTT 33,1Na 134,1 Kontrol APTT 29,6K 3,52 INR 1,15Cl 103AL 12,12AE 4,91
MASALAH
NyeriPenyembuhan luka
Balance Cairan :CM : 2762 cc/24 jamCK : 2035 cc/24 jamIWL : 756 cc/ 24 jamBC : -29 cc/ 24 jamBC kumulatif : -2081 ccDiuresis: 3,1 cc/kgBB/jamUO: 610 cc/5 jam terakhir
Plan Awasi KU/VS/BC Cefixime 100 mg/12 jam Paracetamol 250 mg/8 jam Cetirizine 5 mg/24 jam Zinc 20 mg/24 jam Ondancentron 2 mg/12 jam KCl 1000 mg/8 jam Diet TKTP
![LokLF; vkSj ifjokj dY;k.k ea=kky; - · PDF file4 THE GAZETTE OF INDIA EXTRAORDINARY [P ART II—S EC. 3(i)] ijarq bu fu;eksa ds vèkhu fdlh ,sls O;fDr dks [kk| lqj{kk vfèkdkjh fu;qDr](https://static.fdocuments.in/doc/165x107/5a78b3657f8b9a21538c1f2a/loklf-vksj-ifjokj-dykk-eakky-the-gazette-of-india-extraordinary-p-art-iis.jpg)
