Laporan Jaga ICU 20 Januari 2015

IDENTITASDIAGNOSA

DPJP

coass

HARI PERAWATAN

TANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

22/12/2014 jam 13.06

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans

Balans kumulatifPEMERIK. PENUNJANG

LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat

CD3 (%/absolut)/CD4 (%/absolut)

INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI

analisa cairan asites

HbA1c/Beta hidroksi butirat (Keton)

Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

RT/L/1 thn

colonostomi ec invaginasi+gizi buruk

Dr. Lucky Kumaat,SpAn

Devy, Arny, Fitri

155-173

36-37,8

40-42

Konj. Anemis -/- Sklera ikterik -/-

SI-II n regular, bising -, murmur -

Sp. Vesikuler, Rh-/-, Wh-/-

I : datar, A : BU(+), Pal: lemas

PO2/FIO2 28,4

370 cc cc

cc

cc/kgBB/ 24 jam

19 Januari 2015

12,1/ 33,5/ 15.100/ 301.000

26/6,5

33/19

20 Januari 2015 (Hari Perawatan ke 1)

pH 7,487/pCO2 24,2/pO2 79.5/HCO3 18.5/BEecf -5,1/SO2 96/Hb 8,4/Hct 25



Cefotaxime 3X250gentamicin 1x40

IDENTITASDIAGNOSA

DPJPcoass

HARI PERAWATANTANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

Mixed Vein

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans


LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat


INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI



Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

JO/L/21thPost laparatomi eksplorasi e.c. vulnus ictum penetrasi abdomen + WSD + Efusi pleura sinistra + sepsis + melena


Devy, Arny, Fitri

120- 135

70- 90

100- 130

36,5-37,5

35- 40

98%-100%

E4V5M6





PO2/FIO2 353,8

1750 cc

850 cc

17 cc/kgBB/24 jam

19/01/2015


pH 7,480/pCO2 27,2 /pO2 113,2/HCO3 20,5/ BE 3,2/ SO2 98,1/ Hb 9,6/ Hct 29

8,5/ 25,9/ 5.100/ 248.000

40/ 0,6

2,2

Meropenem 3 x 1 gr

Omeprazole 2 x 40 mg

Asam Traneksamat 3 x 500 mgVit C 1 x 100 mg

Vit K 1x1 amp

IDENTITASDIAGNOSA

DPJP

coass

HARI PERAWATAN

TANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

22/12/2014 jam 13.06

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans


LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat


INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI



Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

MW/L/18 thn

ICH + SAH


Devy, Arny, Fitri

100-121

60- 70

54-66

36,0- 36,2

9- 16

99-100%

E2V1M5





PO2/FIO2 471,0

1525 cc

1600 cc

26,6 cc/kgBB/ 24 jam

15 Januari 2015

10,1/ 28,3/ 13.200/ 497.000

27/ 0,8


pH 7,472/pCO2 43,9/pO2 131,9/HCO3 32,4/BEecf 8,5/SO2 98,7/Hb 10,5/Hct 31



Ceftriaxone 3X1Brain act 2 x 500 mg

Ranitidin 2x50mgVit C 2 x 200 mg

Pct drip 2 x 500 mgNimotop 4 x 60 mg (TD> 120/ 90)

Zinc 2 x 1 tabCripsa 2,5 mg 2 - 1 - 0

IDENTITASDIAGNOSA

DPJP

coass

HARI PERAWATAN

TANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

22/12/2014 jam 13.06

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans


LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat


INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI



Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

AK/L/1 thn

Obstruksi usus mekanik total e.c susp. Invaginasi post laparatomi eksplorasi

dr. Iddo Posangi, SpAn

Devy, Arny, Fitri

70

40 - 50

90 - 116

36,0 - 36,2

36 - 40

88 - 98 %

E2VxM3

Konj. Anemis +/+ Sklera ikterik -/-




PO2/FIO2 98,6

250 cc350 cc


pH 7,5/pCO2 14,7/pO2 96,8/HCO3 13,0/BEecf -9,5/SO2 98,6/



cefotaxime 3 x 300 mg gentamicin 1 x 80 mg

ondancentron 3 x 2 mg

IDENTITAS

DIAGNOSA

DPJP

coass

HARI PERAWATAN

TANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

Mixed Vein

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans


LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat


INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI



Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

JA/L/40th

Tumor recti post laporatomi e.c peritonitis

Perforasi Colon transversum

dr. Iddo Posangi ,SpAn

Simone, Roger, Januarita, Stella, Tami

150 - 200

90 - 110

135 - 144

37

30 - 37

86 - 96

E4V5M6





250 cc350 cc

100 cc




Ceftriaxone 2x1 gr iv

Ranitidin 2x50 iv

Tramadol 3x1 iv

Metronidazole

Clinimix 400

IDENTITASDIAGNOSA

DPJP

coass

HARI PERAWATAN

TANDA VITAL

TD Sistolik

TD Diastolik

N

S

P

SPO2

Kesadaran

Mata

Jantung

Paru

Abdomen

VENTILASIMOV

AGD

22/12/2014 jam 13.06

BALANS CAIRANCM

CK

UrineUo (cc/kg/jam)

Balans


LABORATORIUM

Hb/Hct/Leu/Tr

Na/K/Cl

Ureum/Creatinin

SGOT/SGPT

GDP

Bilirubin T/D/I

PT/APTT

Protein T/A/G

CK/CK-MB

Ca/Mg

Fib

D-dimer/Fibrinogen

Albumin

Kultur

Laktat


INR

LED

PCT

Px Penunjang lain

Cxr

Echo

Ctscan thorax

MRI



Kultur

CT Scan Kepala

USG

MASALAH

TERAPI

FL/P/29 thn

Penurunan Kesadaran e.c susp. Sepsis post op ca ovarium

AKI e.c susp. Nefropati (D)

Anemia

dr. Iddo Posangi, Sp. An

Simone, Roger, Januarita, Stella, Tami

55 - 130

30 - 80

100 - 140

30,0 - 37,8

23 - 38

90 - 100%

E2V2M3




I : datar, A : BU(+),luka post op Pal: lemas

PO2/FIO2 367,7

1953 cc

250 cc

1/22/2015

UC/ 25/ /


pH 7,390/pCO2 17,0/pO2 224,3/HCO3 10,3/BEecf - 14,8/SO2 99,8/Hb 8,3/Hct 25



Ceftriaxone 3X1metronidazol 2x0,5mg

Farmadol

Omeprazole 2x1

Transamin 3x1

Laporan Jaga ICU 20 Januari 2015

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