copy of icu baru

Nama/Umur Ny Suyati / 32 thDiagnosis P2A0H33 mgg Post Sc ai

Eklamsia + PJTHARI PERAWATAN hari ke-1

Tanda VitalTD Sistolik 138-155

TD Diastolik 73-93FN 116-130S 36-37P 18-21

TVSKesadaran CM

Pemeriksaan FisikMata CA (-/-), SI (-/-)

Jantung Bj 1- Bj2 reguler, m(-), G(-)Paru vesikuler (+/+), ronchi (-), wh (-)

Abdomen supel, Bu (+), luka op tertutup kasa, kontraksi (+)Ventilasi

MOV NRM 8 lt/mAGD

Mixed VeinBalans Cairan

CM 1387CK 3060

Urine 24 jam 3060 ccIWL

Uo (cc/kg/jam) 2.3 cc/kg/jamBalans -1673

Balans kumulatif -1725.5

Pemeriksaan PenunjangDPL 15,5/48/27800/226000 (10-10-2011)

Elektrolit 138/4,27/104 (10-10-2011)Ureum/Creatinin 21/0,86 (10-10-11)

SGOT/SGPT 42/55 (10-10-11)GDS

Bilirubin T/D/IPT/APTT

Pt/Alb/GlobCa darah

Ca ionMasalah

observasi

Terapi

D5+MgSO4 40% 16 tpmRL+Syntocinon 1A 12 tpm

Ketrobat 3x1ARanitidin 2x1ABioxon 1x2 gr

Rencana

Keterangan

Ny Suyati / 32 th

P2A0H33 mgg Post Sc ai Eklamsia + PJT

hari ke 2

130-17070-9084-98

36-36,514-16

CA (-/-), SI (-/-)Bj 1- Bj2 reguler, m(-), G(-)

vesikuler (+/+), ronchi (-), wh (-)supel, Bu (+), luka op tertutup kasa, kontraksi (+)

Nasal canule 3l/mnt

375920602060

1.216992754

rencana pindah ruangan

D5+MgSO4 40% 16 tpmRL+Syntocinon 1A 12 tpm

Ketrobat 3x1ARanitidin 2x1ABioxon 1x2 gr

Nama/Umur Ny Sakiyam 73thnDiagnosis enchephalopaty ec hiponatremi perbaikan +AF

HARI PERAWATAN hari ke-28TANDA VITAL

TD Sistolik 132-150TD Diastolik 89-111

Frekuensi Nadi 109-125Suhu 36.5-37.3

Laju Nafas 19-25Tekanan VSKesadaran apatis

PEMERIKSAAN FISIKMata ca-/-, Si-/-

Jantung bj I-II (n) m(-)g(-)Paru rh (+/-), wh (-/-)

Abdomen bu (+) n

VENTILASIMOV NRM 6 l/mAGD 7.426/45.7/90.0/29.4/4.2/30.8/97 tgl 5

Mixed Vein

BALANS CAIRANCM 1515

CK 1220Urine 1220

UO (cc/kg/jam) 5 cc/kg/jamIWL

Balans 295Balans kumulatif 6428.9

PEMERIK. PENUNJANGLABORATORIUM

DPLElektrolit

Ureum/CreatininSGOT/SGPT

GDS 160

Protein T/D/ICa

RADIOLOGIS

MASALAHkesadaran (gangguan pola tidur)

schlem ++++++

observasi post ekstubasi

TERAPIAlinamin F 1 x 0.5 amp STOP

Brainact 3 x 250 mg

Pantozol 2 x 0.5 amp

metilprednisolon 3x0.5 amp

Parmadol (k/p)

Notropil 3 x 1 cth

Hp-pro 3 x 0.5 mg

arcalion (pagi-siang)

Fenitoin 2 x 20 mg

inhalasi per 5 jam

Kombifen 0.5 + NaCl

nutrinidrink 8x 125

RENCANA

KETERANGANtarget:

MAP > 80

CVP 10-15

GDS < 150

UO 0,5-1

Elevasi kepala 30

normothermia

Ny Sakiyam 73thnenchephalopaty ec hiponatremi perbaikan +AF

hari ke-32 hari ke 33

132-166 133-16753-97 81-103

146-166 128-16537.4 36,5-38,5

14-18 16-26

ca(-/-) si (-/-) ca(-/-) si (-/-)

Bj 1-2 reguler m(-) g(-) Bj 1-2 reguler m(-) g(-)

vesikuler Rh(+) Wh(-) vesikuler Rh(+) Wh(-)

supel BU(+) supel BU(+)

NC 3 lt/mnt Nasal 4/lt7.41/40.1/252/25 (08-10-11) 7,446/43,2/340,5/4,5/29,1/99,8

1401 1191

760 645760 12003.16 5

+ 641 346+ 9084 9976

11.3/36/10600/468000 (02-10-11) 10,1/30/39000/298000

140/4.5/90 (03-10-11)

35/0.38 (28-09-11)

57/122 (30-09-11)

sputum retensi demam

perbaikan kesadaran

timbang bb/3 hr timbang bb/3 hr

Brainact 3 x 250 mg Brainact 3 x 250 mg

Pantozol 2 x 0.5 amp Pantozol 2 x 0.5 amp

metilprednisolon 3x0.5 amp metilprednisolon 3x0.5 amp

Parmadol (k/p) farmadol (k/p)

Notropil 3 x 1 cth Notropil 3 x 1 cth

Hp-pro 3 x 0.5 mg Hp-pro 3 x 0.5 mg

arcalion (pagi-siang) arcalion (pagi-siang)

Fenitoin 2 x 20 mg Fenitoin 2 x 20 mg

inhalasi per 5 jam inhalasi per 5 jam

Kombifen 0.5 + NaCl Kombifen 0.5 + NaCl

nutrinidrink 8x 125 nutrinidrink 8x 175

pelastin 3x175mg

pindah ruangan

target:

MAP > 80

CVP 10-15

GDS < 150

UO 0,5-1

Elevasi kepala 30

normothermia

Ny Sakiyam 73thnenchephalopaty ec hiponatremi perbaikan +AF

enchephalopaty ec hiponatremi perbaikan +AF

target:

MAP 80-90

CVP 8-12

PaO2 > 100

PaCO2 35-45

Uo> 0,5

Tn.Arianto 37 thn

balans negatif, minimal spasme

CVP 8-14 CVP 8-14

Nama/Umur Tn. Enday 25 tahunDiagnosis Post Op Laparatomi ec. Trauma tumpul abdomen + fraktur costae 3-4-5 dekstra

HARI PERAWATAN hari ke 1 (26-11-2011)TANDA VITAL

TD Sistolik 134 - 165 mmHgTD Diastolik 75 – 95 mmHg

Frekuensi Nadi 82-123 x/menitSuhu 37,2-38,1 ˚C

Laju Nafas 12-18 x/menit Tekanan VS 9,5-15 cmH2OKesadaran Koma (DPO)

Jantung bj I-II (n) m(-)g(-)Paru rh (-/-), wh (-/-)

Abdomen bu (-)

VENTILASIMOVAGD

Mixed Vein

SIMV 10,PSIMV 13,FiO2 50 %, RR 14,

CK 2780Urine 407

UO (cc/kg/jam) 2,7 cc/kg/jamIWL

Balans -20Balans kumulatif -345

DPL 10,1/16900/34700/30

Elektrolit 132/3,24/102

Ureum/Creatinin 32/0,42

SGOT/SGPT 38/32

GDS 132/156

Protein T/D/I 5,42/2,66/2,76

CK CKMB TROPONIN T

RADIOLOGISSUSP LACUNAR ISKEMIK PARIETAL BILATERAL

MASALAHAF

HIPOALBUMIN

TERAPImanitol 4x75

ranitidin 3x1

kalmetason 4x1amp

neurotam 4x1amp

ceftri 1x2gr

Laxadine 1x1c

Lasix 1x1 amp

sumagesic 3x1

captopril 3x12,5

phenitoin 3x1

nuchral 4x10cc

aspar k 1x1

fluimucyl 3x1

cordaron drip

RENCANA

KETERANGAN

Tn. Enday 25 tahunPost Op Laparatomi ec. Trauma tumpul abdomen + fraktur costae 3-4-5 dekstra

SUSP LACUNAR ISKEMIK PARIETAL BILATERAL

Tn. Enday 25 tahunPost Op Laparatomi ec. Trauma tumpul abdomen + fraktur costae 3-4-5 dekstra

Post Op Laparatomi ec. Trauma tumpul abdomen + fraktur costae 3-4-5 dekstra

target:

MAP 80-90

CVP 8-12

PaO2 > 100

PaCO2 35-45

Uo> 0,5

Tn.Arianto 37 thn

CVP 8-14 CVP 8-14

Nama/Umur Ny Isnaini (Dr marwattal SpS)Diagnosis Penurunan Kesadaran ec Stroke Hemoragik

HARI PERAWATANTANDA VITAL

TD Sistolik xTD Diastolik x

Frekuensi Nadi 45-55Suhu 36.5-37.3

Laju Nafas 19-25Tekanan VSKesadaran koma

Jantung bj I-II (n) m(-)g(-)Paru rh (+/-), wh (-/-)

Abdomen bu (+) n

VENTILASIMOVAGD

Mixed Vein

CK 1260Urine 1260

UO (cc/kg/jam) 1 cc/kg/jamIWL

Balans 227Balans kumulatif 6428.9

DPL 12,3/1800/223000/38

Elektrolit 145/4.42/93

Ureum/Creatinin 0,83/60

SGOT/SGPT 60/65

GDS 184

Protein T/D/ICa

RADIOLOGIS

MASALAH

TERAPIManitol 4x125

neurotam 4x3gr

Simvastatin 1x20mg

Aspar K 1X1

Panzo 1x1 tab

Cordaron tab

RENCANA

KETERANGAN

Ny Isnaini (Dr marwattal SpS)Penurunan Kesadaran ec Stroke Hemoragik

Penurunan Kesadaran ec Stroke Hemoragik

target:

MAP 80-90

CVP 8-12

PaO2 > 100

PaCO2 35-45

Uo> 0,5

Tn.Arianto 37 thn

CVP 8-14 CVP 8-14

Nama / Umur Ny. Eliza Arief, 70 th

Diagnosis CVD iskemik lama, gagal nafas tipe IIsepsis susp CAP

HARI PERAWATAN 1. 28/6/09TANDA VITAL

Frekuensi Nadi 90-130Suhu 36-37

Laju Nafas 12-16TVS

Kesadaran CMPEMERIKSAAN FISIK

Mata ca-/-, Si-/-Jantung bj I-II (n) m(-)g(-)

Paru dbnAbdomen bu (+) n

VENTILASIMOV MRM 8l/mAGD 7,426/33,0/124,0/-2,1/21,3/98,7

Mixed VeinBALANS CAIRAN

CM 1043.4CK 600

Urine 600

UO (cc/kg/jam) 0.7IWL 600

Balans -156.6Balans kumulatif

DPL 6,7/20,4/22300/189000Elektrolit 130/4,0/95

Ureum/Creatinin 90/0,6SGOT/SGPT 94/261

GDSBilirubin T/D/I

PT/APTTProtein T/A/G

RADIOLOGIS

MASALAH

TERAPI

meropenem 3x1

nicholin 1500dumin 4x1ritalin 2x1/2 tabmadofar 3x1 tabbisoprolol 2,5simvastatin 10

KAEN Mg3aseringgelofusindopamin drip 5 mcg/kg/mnt

RENCANA

KETERANGAN

CVD iskemik lama, gagal nafas tipe II

2. 29/6/09 3. 30/6/09

90-110 110-13050-60 60-70

90-110 90-11036-37 37-3820-24 20-24

ca-/-, Si-/- ca-/-, Si-/-bj I-II (n) m(-)g(-) bj I-II (n) m(-)g(-)

dbn dbnbu (+) n bu (+) n

MRM 8l/m SM 8l/m7,426/33,0/124,0/-2,1/21,3/98,7

2547 31181770 15001770 1500

1.2 1.04600 600177 101820.9 1038

8,7/24,4/19300/219000 7.8/24/16700/211000134/4.4/99

Alb 2.57

meropenem 3x1 meropenem 3x1

nicholin 1500 nicholin 1500dumin 4x1 dumin 4x1ritalin 2x1/2 tab ritalin 2x1/2 tabmadofar 3x1 tab madofar 3x1 tabbisoprolol 2,5 bisoprolol 2,5simvastatin 10 simvastatin 10

KAEN Mg3 KAEN Mg3asering aseringgelofusin gelofusindopamin drip 5 mcg/kg/mnt dopamin drip 5 mcg/kg/mnt

4. 1/7/09

110-14050-90

100-13038-3920-28

E3M4V1

ca-/-, Si-/-bj I-II (n) m(-)g(-)

dbnbu (+) n

SM 8l/m

260719501950

9.6/29/26500/253000132/4.5/9

meropenem 3x1

nicholin 1500dumin 4x1ritalin 2x1/2 tabmadofar 3x1 tabbisoprolol 2,5simvastatin 10

KAEN Mg3aseringgelofusindopamin drip 5 mcg/kg/mnt

Nama / Umur Ny. Amisah / 50 thnDiagnosis ICH Ganglia basalis, ventrikel lateral kiri

HARI PERAWATAN 1. 26/6/09TANDA VITAL

Frekuensi Nadi 70-80Suhu 37

Laju Nafas 12-14TVS

Kesadaran DPOPEMERIKSAAN FISIK

Mata CA -/-, SI -/-Jantung S1-S2 N, M(-),G(-)

Paru Ves, Rh -/-, Wh -/-Abdomen BU (+) N

VENTILASIMOV VC 450/5/40AGD 7,384/44,2/198,4/-36/20,3/98,4

BalansBalans kumulatif

DPLElektrolit 143/3,9/100

Ureum/CreatininSGOT/SGPt

GDSBilirubin T/D/I

Troponin T/CKMBProcalcitoninRADIOLOGIS

MASALAH

TERAPI

cefotaxim 3x1 grOMZ 1x40tramal 3x100mgvit K 1x1VIT C 1X1narfoz 3x4mg

aseringnsns + perdipine 10mg

RENCANA

KETERANGAN

Ny. Amisah / 50 thnICH Ganglia basalis, ventrikel lateral kiri

2.27/6/09 3.28/6/09

110-160 120-16070-80 70-8060-80 60-8036-37 36-3712-24 12-24

4-7 6-10cm E2M5Vtube

CA -/-, SI -/- CA -/-, SI -/-S1-S2 N, M(-),G(-) S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/- Ves, Rh -/-, Wh -/-

BU (+) N BU (+) N

VC 450/5/35 PC SIMV 10/5/357,484/28,2/198,4/0,3/20,3/98,4

2460,5 25551520 8951520 895

1,2 0.8500 500

440,5 1160440,5 1600

14,1/43,7/15.800/254.000

142/3,4/99

15/0,8

19,0(12,6)/250,2(32,2)

cefotaxim 3x1 gr cefotaxim 3x1 grOMZ 1x40 OMZ 1x40tramal 3x100mg tramal 3x100mgvit K 1x1 vit K 1x1VIT C 1X1 VIT C 1X1narfoz 3x4mg narfoz 3x4mg

Ny. Amisah / 50 thnICH Ganglia basalis, ventrikel lateral kiri

4.29/6/09 5.30/6/09

140-160 110-15080-90 60-8060-80 70-10036-37 37.2-37.712-24 13-1813-18 13-18

E2M5Vtube E2M5Vtube

BU (+) N BU (+) N

PC SIMV 12/5/35

3571 37531410 11501410 1150

1.1 0.9500 500

1661 21033261 5364

11.0/38

138/3.1/98

11.9(11.8)/33.8(33.5)

cefotaxim 3x1 gr cefotaxim 3x1 grOMZ 1x40 OMZ 1x40tramal 3x100mg tramal 3x100mgvit K 1x1 vit K 1x1VIT C 1X1 VIT C 1X1narfoz 3x4mg narfoz 3x4mg

6.1/7/09

120-15070-90

70-10037-3812-18

E4M5Vtube

CA -/-, SI -/-S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/-

BU (+) N

245429502950

500-9964368

134/3.4/93

cefotaxim 3x1 grOMZ 1x40tramal 3x100mgvit K 1x1VIT C 1X1narfoz 3x4mg

Nama / Umur Tn. Ahmad wasidi, 50 thDiagnosis tetanus score 15 (H+7)

HARI PERAWATAN 2(21/6/09)TANDA VITAL

Frekuensi Nadi 60-80Suhu 36-36,7

Laju Nafas 16-20TVS

Kesadaran E1M2VtubePEMERIKSAAN FISIK

Mata CA -/-, SI -/-Jantung S1-S2 N, M(-),G(-)

Paru Ves, Rh -/-, Wh -/-Abdomen BU (+) N

VENTILASIMOV PC 12/8/45AGD 7,373/40,3/141,6/1,9/26,6/98,7

CM 3040CK 2525

Urine 2375

UO 1.7IWL 550

Balans -34.7Balans kumulatif 239.8

DPL 11,5/37/7000/211000Elektrolit 139/2,7/98

Ureum/Creatinin 14/1,1SGOT/SGPt 18/11

GDS 135Bilirubin T/D/I

PT/APTT 14(13)/31(34)Protein T/A/G 2.53

Troponin T/CKMBProcalcitoninRADIOLOGIS

MASALAH

TERAPI

ceftazidim 2x1 g

OMZ 40

metronodazol 3x500

vit C 1 x 600

tramal 3x100

TF E 1000KAEN Mg3

mo 1 mg/ j

DZP 300 /24 j

MgSO4 bolus 2 g dlm 15'

lalu 1 g/ j

inhalasi

hemacell, NS

RENCANA

KETERANGAN

Tn. Ahmad wasidi, 50 thtetanus score 15 (H+7)

3(22/6/09) 4(23/6/09)

120-130 100-13070-80 70-8060-80 60-90

36-36,7 36-36,716-20 7,5-13

7,5-13E2M2Vtube E2M2Vtube

BU (+) N BU (+) N

PC 12/8/45 PC 12/8/457,473/50,3/101,6/5,9/30,6/98,7

2911 34962430 16602380 1660

1.8 1.2550 550-69 1285170 1456

139/3,3/108

14(13)/31(34)

Mg 5,5Ca 7,1

CXR : BP

ceftazidim 2x1 g ceftazidim 2x1 g

OMZ 40 OMZ 40

metronodazol 3x500 metronodazol 3x500

vit C 1 x 600 vit C 1 x 600

tramal 3x100 tramal 3x100

TF E 1000 TF E 1000KAEN Mg3 KAEN Mg3

mo 1 mg/ j mo 1 mg/ j

DZP 300 /24 j DZP 300 /24 j

inhalasi inhalasi

hemacell, NS hemacell, NS

Tn. Ahmad wasidi, 50 thtetanus score 15 (H+7)

5(24/6/09) 6(25/6/09)

100-130 100-13060-80 60-80

100-120 100-12036-36,7 37-3810-16 10-16

11-15E2M2Vtube E2M2Vtube

BU (+) N BU (+) N

SIMV PC 14/8/45 SIMV PC 14/8/457,453/50,3/171,6/9,9/34,6/98,7

7,4/46,3/47,6/3,9/28,6/83,7

2736 20751820 10501770 1050

1.3 0.7550 1000

366.5 8251822.4 2647

11,9/36,6141/3,4/96 140/3,5/96

57/1,034/56

CXR : BP

OMZ 40 OMZ 40

vit C 1 x 600 vit C 1 x 600

DZP 300 /24 j DZP 300 /24 j

inhalasi inhalasi

7(26/6/09) 8(27/6/09)

100-130 100-13060-70 50-80

100-120 60-10037-38 36-3710-16 12-1811-15 12-15DPO DPO

BU (+) N BU (+) N

SIMV PC 14/8/45 PC PS 14/14/8/507,440/39,6/100,7/3,2/27,0/97,67,455/41,0/44,6/4,6/28,4/82,5

3214 3197,61050 18251050 1825

0,7 1,381000 10001164 372,6

3631,9 4004

9,9/30,9/5800/271000141/3,6/97 140/3,5/98

72/34 51/0,792/34

alb : 2,3

OMZ 40 OMZ 40

vit C 1 x 600 vit C 1 x 600

DZP 300 /24 j DZP 300 /24 j

inhalasi inhalasi

9(28/6/09) 10(29/6/09)

110-130 110-13060-70 60-70

90-120 90-12037-38 37-3812-22 12-2211-15 11-15DPO DPO

BU (+) N BU (+) N

SIMV PC 14/8/40 PS 12/6/40

2897 2177920 950920 950

0.6 0.71000 1000977.4 227

4981.4 5209

16,5(13,2)/37,4(31,3)

Ca 10,1Mg 1,7

sputum : E. coliacinobacter sp

OMZ 40 OMZ 40

vit C 1 x 600 vit C 1 x 600

DZP 300 /24 j DZP 300 /24 j

inhalasi inhalasi

tetrasiklin 4x500

11(30/6/09) 12(1/7/09)

100-140 100-14060-80 60-80

80-110 80-11036.3 36.3

20-28 20-2813.5 14-16DPO E3M5Vtube

BU (+) N BU (+) N

PS 6/6/40 PS 12/6/35

2707 20461250 14501250 1050

0.71000 1000457 -404

5666 5262

10.6/32.7137/3.2/100 136/3.5/98

OMZ 40 OMZ 40

vit C 1 x 600 vit C 1 x 600

DZP 300 /24 j DZP 300 /24 j

inhalasi inhalasi

tetrasiklin 4x500 tetrasiklin 4x500

Nama / Umur Diagnosis

TD SistolikTD Diastolik

Frekuensi NadiSuhu

Laju NafasTVS

KesadaranPEMERIKSAAN FISIK

MataJantung

ParuAbdomen

VENTILASIMOVAGD

IWLUo (cc/kg/jam)

DPLElektrolit

GDSBilirubin T/D/I

PT/APTTProt T/A/G

Ca darah

RADIOLOGIS

MASALAH

TERAPI

RENCANA

KETERANGAN

Tn. Lorenz Gunach, 52 thHHD, SH batang otak, sepsis

1. 29/6/09

90-15060-80

90-12036-37

12 s/d 16

E1M1Vtube

ca-/-, Si-/-bj I-II (n) m(-)g(-)

dbnbu (+) n

PC 16/5/607,025/69,6/126,5/-9,3/18,8/96,7

611.8850850

1.7350

-588.2-588.2

11,6/35,7/9700/65000134/6,3/107

122/9,285/141

13,9(12,4)/43,2(32)

ro thorax : infiltrat paru kiri dan kanan, CVC di Th 6

cefobid 2x2 g

avelox 1x400pantozol 40vit c 1 gtransamin 3x500vit Kphenitoin 3x100bicnat 3x500laxadin 3x C1aseringhaemacelmartos 10%

Tn. Lorenz Gunach, 52 thHHD, SH batang otak, sepsis

2. 30/6/09

120-16060-10090-110

37.115-16

E1M1Vtube

ca-/-, Si-/-bj I-II (n) m(-)g(-)

dbnbu (+) n

PC 16/5/40

263122502250

3501.3381-207

12.1/37.3136/5.8/102

cefobid 2x2 g

HHD, SH batang otak, sepsis

3. 1/7/09

90-13060-90

100-12037-3916-24

E1M1Vtube

ca-/-, Si-/-bj I-II (n) m(-)g(-)

dbnbu (+) n

PC 16/5/50

280917901290

3191030

139/4.9/105

13.2(13.4)/43.8(30.3)

cefobid 2x2 g

Frekuensi NadiSuhu

Laju NafasTVS

MataJantung

ParuAbdomen

VENTILASIMOVAGD

IWLUO(cc/kg/jam)

DPLElektrolit

GDSBilirubin T/D/I

PT/APTTProtein T/A/GRADIOLOGIS

MASALAH

TERAPI

RENCANA

KETERANGAN

Tn.Tan Boenpost op laringektomi total ec.KSS laring

1. 30/6/09

140-12080-10060-8035-3716-20

ca-/-, Si-/-bj I-II (n) m(-)g(-)

dbnbu (+) n

T-piece 3l/mnt7,49/30,0/160,7/22,7/0,5/98,4%

51010001000

6000,69

12,6/39/7600/344000140/4,3/103

33/1,028/23

10,6(10,3)/31,5(35,1)

ceftazidim 2x1gr

dexamethason 3x10mgOMZ 1x40mgvit K 3x10tramadol 3x100mgondansetron 3x4mg

aseringhaemacel

post op laringektomi total ec.KSS laring

Frekuensi NadiSuhu

Laju NafasTVS

MataJantung

ParuAbdomen

VENTILASIMOVAGD

IWLUO(cc/kg/jam)

DPLElektrolit

GDSBilirubin T/D/I

MASALAH

TERAPI

RENCANA

KETERANGAN

Tn. Syafrudin, 48 thdispnea akut, susp emboli paru + TB paru on OAThemoptisis + sepsis

2. 29/6/9

80-13050-85

120-15036-3716-1811-21DPO

CA +/+, SI -/-S1-S2 N, M(-),G(-)

Ves, Rh +/+, Wh -/-BU (+) N

PC 15/5/607,141/62,2/99/-5,4/22,4/98,7

4811100100

0.0850042114437

8,3/25,6/21700/142000

138/5,0/106

17/0,9

22(13)/25(31)

ceftazidim 3x1

levoflox 1x500

vit c 1x1

omz 1x40mg

vit B6

heparin 2x 5000

PCT 3x500

asering

KAEN Mg3

vascon 0,5 mcg

dispnea akut, susp emboli paru + TB paru on OAThemoptisis + sepsis

3.30/6/9 4.1/7/09

80-130 100-12040-70 60-80

120-140 120-14036-38 36-3716-28 20-3014-18 14-18DPO DPO

CA +/+, SI -/- CA +/+, SI -/-S1-S2 N, M(-),G(-) S1-S2 N, M(-),G(-)

Ves, Rh +/+, Wh -/- Ves, Rh +/+, Wh -/-BU (+) N BU (+) N

PC 15/5/60 PC 15/8/50%7,175/65,5/61,3/23,2/-5,4/93,2%7,347/34,4/187,7/18,4/-6,1/98,7%

3108 2701,2440 270140 70

550 5500,106 0,052118 1881,2

6555,5 8436,7

9,4/30,9/13.600/168.000133/5,3/97

89/2,731/16

270 195

15,1(64,2)/11,8(33,5)

ceftazidim 3x1 ceftazidim 3x1

levoflox 1x500 levoflox 1x500

vit c 1x1 vit c 1x1

R/E/S R/E/S

omz 1x40mg omz 1x40mg

vit B6 vit B6

heparin 2x 5000 heparin 2x 5000

PCT 3x500 PCT 3x500

asering

KAEN Mg3

vascon 0,5 mcg

7,347/34,4/187,7/18,4/-6,1/98,7%

Frekuensi NadiSuhu

Laju NafasTVS

MataJantung

ParuAbdomen

VENTILASIMOVAGD

IWLUO(cc/kg/jam)

DPLElektrolit

GDSBilirubin T/D/I

RADIOLOGIS

MASALAH

TERAPI

RENCANA

KETERANGAN

tn. Rahmat hidayat, 51 thsyok hipovolemik + gagal nafas pascareseksi anastomosis ai CA gaster post relap

1(16/06/09)

100-12060-90

110-14036-36,720-307-13DPO

BU (+) N

PC 12/5/407,49/26,3/101/20/-1,9/98

2788830380

1.02350

16081608

11,1/37,5/5,7/147132/3,1/103

66/0,6

20,4(13,3)/54,3(32,3)

ceftazidim 2x1 g (H+9)

levoflox 1x500 (H+1)OMZ 40vit c 1 gtransamin 3x500

TF 1000PRC 2 ktg

tn. Rahmat hidayat, 51 thsyok hipovolemik + gagal nafas pascareseksi anastomosis ai CA gaster post relap

2(17/06/09)

100-12060-90

90-11036-36,720-3013-15DPO

CA +/+, SI -/-S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/-

BU (+) N

PC 12/5/407,31/36,3/95/20/-6,9/98

2029.5555270

0.35350

1124.52732.5

9,1/27,5/10,7/96.136/3,6/103

81/1,1

16,4(13,3)/62,3(32,3)

fib 384d dimer 300

CXR efusi berkurang

TF 1000PRC 1 ktg

modorpetidin 100/ 8 jamvascon 4 mg

syok hipovolemik + gagal nafas pascareseksi anastomosis ai CA gaster post relap

3(17/06/09)

100-12060-90

100-11036-36,720-3010-15DPO

BU (+) N

PC 12/6/407,39/26,3/101/20/-,39/98

28741090675

0.51550

1234.73967.2

11,1/33,5/12,7/147135/3,9/103

107/2,231/19

13(13)/41(33)

clinimixPRC 2 ktgalbumin 100tramadol 100/8jmetoclopramid 3x1vit kmetronidazol 3x500

vascon + dobu

6(21/06/09) 7(22/06/09)

110-120 90-13060-90 60-90

110-120 90-11036-36,7 36-36,712-18 12-1813-15 14-18DPO DPO

CA +/+, SI -/- CA +/+, SI -/-S1-S2 N, M(-),G(-) S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/- Ves, Rh -/-, Wh -/-

BU (+) N BU (+) N

PC 15/7/45 PC 15/7/457,26/46,2/161/-5,4/20,4/97,7 7,27/42,2/261/-6,4/20,4/97,7

3163.6 35335252 20801370 460

1.03 0.5550 350

-2638.4 1103142.9 1746

9,1/28,5/16,7/106. 5,3/16,2/21/96.136/3,6/99 136/4,6/99

183/2,3 187/2,713/8

137 232

16,4(13,3)/62,3(32,3) 26,4(13,3)/92,3(32,3)1.74 0.89

BP, efusi bilWSD +

sulferazone 2x1 g sulferazone 2x1 g

metronidazol 3x500 metronidazol 3x500OMZ 40 OMZ 40vit c 1 g/ vit k 3x10 vit c 1 g/ vit k 3x10transamin 3x500 transamin 3x500lasix 3x2 amp lasix 3x1 ampketesse 2x1 amp ketesse 2x1 amptramal 100/8 j tramal 100/8 jNTG 10 (1,5 mcg) NTG 10 (1,5 mcg)modor modorcordaron 300/12 j cordaron 300/12 jvascon 4 mg vascon 4 mgdobu 250 dobu 250albumin 25 % albumin 25 %

RI 2,5 U/ jTF 1600, T 1000, Amiparen TF 1600, Amiparen

rencana relaparotomi

8(23/06/09) 9(24/06/09)

120-140 140-15060-90 60-90

90-110 90-11036-36,7 36-36,712-18 12-1812-14 15-18DPO DPO

BU (+) N BU (+) N

PC 15/6/45 SIMV PC 16/6/457,43/32,2/161/-2,4/20,4/97,77,37/35,2/86/-3,4/20,4/97,7

7,376/39,2/44/-1,4/22,4/84,7

4198 26556125 43354340 3310

3.2 2.5550 550

-2477 -2229.5-730.8 -2685.3

7,8/18,2/14./96. 9,8/29,2/22.6/186.136/3,6/99 143/3,4/99

167/3,1 174/2,1

19,4(13,3)/43,3(32,3)

Fib 245D Dimer 100

meronem 3x1 meronem 3x1

metronidazol 3x500 metronidazol 3x500OMZ 40 OMZ 40vit c 1 g/ vit k 3x10 vit c 1 g/ vit k 3x10transamin 3x500 transamin 3x500lasix 3x1 amp lasix stop

tramal 100/8 j tramal 100/8 jNTG 10 (1,5 mcg) NTG 10 (5 mcg)modor modorcordaron 300/12 j cordaron 300/12 jvascon 4 mg vascon 4 mgdobu 250 dobu 250albumin 25 % albumin 25 %RI 0,5 U/ j RI stopTF 1600, Amiparen TF 1600, Amiparen

10(25/06/09) 11(26/06/09)

120-140 110-16060-90 40-90

90-110 80-11037,5 37,5

12-18 12-2014-19 14-19DPO DPO

BU (+) N BU (+) N

SIMV PC 14/6/45 SIMV PC 14/8/457,39/45,2/96/0,4/25,4/97,77,414/45,1/120,1/3,9/28,4/98,5

7,376/39,2/44/-1,4/22,4/84,7

3229 3916,53505 52503150 4215

2.3 2,0550 550-826 -18835

-3511 -53948

9,5/29,2/28.6/279.148/3,8/99 149/3,7/110

129/1,09/13

metronidazol stop metronidazol stopOMZ 40 OMZ 40vit c 1 g/ vit k 3x10 vit c 1 g/ vit k 3x10transamin 3x500 transamin 3x500

tramal 100/8 j tramal 100/8 jNTG 10 (5 mcg) NTG 10 (5 mcg)modor modorcordaron 300/12 j cordaron 300/12 jvascon 4 mg vascon 4 mgdobu 250 dobu 250albumin 25 % albumin 25 %RI 1 u/ j RI 1 u/ jTF 1600, Amiparen TF 1600, Amiparen

12(27/06/09 13(28/06/09)

120-150 110-14050-70 60-80

90-110 100-12038-39 37,518-28 20-24

11-13,5 11-12DPO DPO

BU (+) N BU (+) N

PC PS 15/15/8/50 PC 15/6/507,386/49,3/96,4/4,0/28,9/97,67,384/49,1/96,1/3,9/28,4/98,57,381/50,8/45,7/4,2/29,4/85

3192,5 2585.83300 30203110 2770

2,3 2.1550 550

-984.2-60523 -7036.2

7,1/22,2 7,8/24/26./421.152/3,8/109 149/3,4/110

alb 2,0

metronidazol stopOMZ 40 OMZ 40vit c 1 g/ vit k 3x10 vit c 1 g/ vit k 3x10transamin 3x500 transamin 3x500aspar k 3x1 aspar k 3x1flumucil 3x1 flumucil 3x1tramal 100/8 j tramal 100/8 jNTG 10 (5 mcg) NTG 10 (5 mcg)modor dorcordaron 300/12 jvascon 4 mgdobu 250 asering/NSalbumin 25 % albumin 25 %RI 1 u/ j RI 1 u/ jTF 1600, Amiparen TF 1600, Amiparen

14(29/06/09 15(30/06/09

120-140 100-14060-80 60-80

90-110 90-11038-39 37-3920-26 18-26

11-13,5 11-14.5DPO DPO

BU (+) N BU (+) N

PC PS 15/6/60 PC PS 18/6/607,486/41,3/78,4/8,0/32,9/97,67.434/52/84/9.3/34/3/97.2

2774 37523835 19903050 1675

2.3 550550 1.26

-1610 1212-8647 -7435

8,8/28,8/23500/400rb 9/29.4/19900/265000152/4,1/109 151/3.9/101

19.7(11.8)/40.6(33.5)Alb 2.1

metronidazol stop metronidazol stopOMZ 40 OMZ 40vit c 1 g/ vit k 3x10 vit c 1 g/ vit k 3x10transamin 3x500 transamin 3x500

flumucil 3x1 flumucil 3x1tramal 100/8 j tramal 100/8 jNTG 10 (5 mcg) NTG 10 (5 mcg)modor modor

peptamen peptamen

albumin 25 % albumin 25 %RI 1 u/ j RI 1 u/ jTF 1600, Amiparen TF 1600, Amiparen

Frekuensi NadiSuhu

Laju NafasTVS

MataJantung

ParuAbdomen

VENTILASIMOVAGD

UO(cc/kg/jam)IWL

DPLElektrolit

Protein T/A/GGDS

CK/CKMBTrop T

RADIOLOGIS

MASALAH

TERAPI

RENCANA

KETERANGAN

Ny.TukiyemPost fixation ec.fracture V thoracal 5-7

1(1/7/09)

100-18080-10070-10037-38

18-Dec6-8,5DPO

CA +/+, SI -/-S1-S2 N, M(-),G(-)

Rh -/-,wh-/-BU (+) N

VC 300/5/60%7,29/31,1/251,7/14,5/-10,7/98,4%

461940502100

1,9450119

3,3/10,2/5700/64000134/4,2/107

24/0,59/-

44,7(12)/>200(30,8)

transamin 3x500

vit c, vit k

ondansetron 2x4 mgOMZ 1x40ceftriaxon 1x2gr

Asering, NaclKAEN Mg3PRC 3 ktgFFP 5 ktggelofuchsin

Post fixation ec.fracture V thoracal 5-7

Nama / Umur Ny. Ferawati,25 thDiagnosis eklampsia G1P1H31mgg,IUFD,edema serebri

prdrhn intraparenkimal luas, DIC, HELLP syndroma

HARI PERAWATAN 1(28/06/09)TANDA VITAL

FN 130-140S 36-36,7P 16-20

TVSKesadaran DPO

PEMERIK. FISIKMata CA-/-, SI-/-

Jantung S1-S2 N, M(-),G(-)Paru Ves, Rh -/-, Wh -/-

Abdomen BU (+) NVENTILASI

MOV VC 500/6/50AGD 7,429/21,9/128,9/-8,1/13,9/98,3

CM 417CK 100

Urine 100IWL 0.27

Uo (cc/kg/jam) 150Balans 167

Balans kumulatif 167PEMERIK. PENUNJANG

LABORATORIUMDPL 11,8/36,2

Elektrolit 141/3,9/102

GDSBilirubin T/D/I

Ca darahPro Calcitonin

CRPPx Penunjang lain

MASALAH

TERAPIceftriaxone 1x2 g

radin 2x50

vit k 3 x 10 mg

vit C 1 x 1 gr

mo-dor

transamin3x1

NS, hemacell

induxin 2 amp

NTG 10 mg

perdipine

RENCANA

KETERANGAN

Ny. Ferawati,25 theklampsia G1P1H31mgg,IUFD,edema serebriprdrhn intraparenkimal luas, DIC, HELLP syndroma

2(29/06/09) 3(30/06/09)

130-150 140-16080-90 80-100

100-120 100-12036,5-38 36,5-3812-18 12-18

DPO DPO

CA+/+, SI-/- CA+/+, SI-/-S1-S2 N, M(-),G(-) S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/- Ves, Rh -/-, Wh -/-

BU (+) N BU (+) N

VC 500/6/60 VC 500/7/50

3289 9981110 751100.07 600

6001579 3231746 2069

8.7/26.1/13400/57000

141/4.7/106

119/4.1

ceftriaxone 1x2 g ceftriaxone 1x2 g

radin 2x50 radin 2x50

vit k 3 x 10 mg vit k 3 x 10 mg

vit C 1 x 1 gr vit C 1 x 1 gr

mo-dor mo-dor

deksametason 2x10 deksametason 2x10

transamin3x1 transamin3x1

NS, hemacell NS, hemacell

induxin 2 amp induxin 2 amp

NTG 10 mg NTG 10 mg

perdipine perdipine

Ny. Ferawati,25 theklampsia G1P1H31mgg,IUFD,edema serebri

4(01/07/09)

140-18080-100

100-14037-38

Dec-09

CA+/+,SI-/-S1-S2 N, M(-),G(-)Ves, Rh -/-, Wh -/-

BU (+) N

PC 11/10/50%

2266,5235235600

0,1631431,53500,5

ceftriaxone 1x2 g

radin 2x50

vit k 3 x 10 mg

vit C 1 x 1 gr

mo-dor

deksametason 2x10

transamin3x1

perdipine

lasix 5mg/jam drip

Ny. Ferawati,25 theklampsia G1P1H31mgg,IUFD,edema serebri

Frekuensi NadiSuhu

Laju NafasTVS

MataJantung

ParuAbdomen

VENTILASIMOV

AGDMixed Vein

BALANS CAIRANCMCK

IWLUO(cc/kg/jam)

DPLElektrolit

GDSBilirubin T/D/I

MASALAH

TERAPI

RENCANA

KETERANGAN

Tn. Suharli, 63 thpost RND dx ec Ca papiler tiroid T3N1M0

1(30/6/09)

110-12060-8070-90

CA +/+, SI -/-

PS 500/5/407.369/36.8/138/20.7/-3.6/97.8

970600600

5500.4

-180-180

10/30.7/8500/174.000135/5.2/97

Asering, Nacl

KAEN Mg3

PRC 2 ktg

target sistolik 140-160

post RND dx ec Ca papiler tiroid T3N1M0

gentamisin 2x80

cordaron 300/24jamciticolin 2x1 g

clopidogrel 1x75aspilet 1x80eselgan 0-0-1

OMZ 1x40ritalin 1x 1/2 tab

vascon - dobu

copy of icu baru

ns tetrasiklin 4x500

modor cordaron 300 12

3x10 transamin 3x500

simv pc 14 8 45

balans cairancm ck

1x1 narfoz 3x4mg

balans balans kumulatif

transamin 3x500 vit

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