kasus 1.doc
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7/17/2019 kasus 1.doc
http://slidepdf.com/reader/full/kasus-1doc-568eda95909dc 1/18
PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
DOKUMEN ASUHAN KEFARMASIAN LAPORAN KASUS
__________________________________________________________________
Inisial Pasien: Tn. W Berat Badan: 41 kg Ginjal: +
Umur : 64 !"#n Tini Badan: $ %& He!ar:"
Kelu#an utama:
S'(!k n!)!(
Dian$sis:
*KD (!g' + HT + SO, -Short Of Breath.
Ri%a&at Pen&a'it:
• *KD ('/!k 4 !"#n !ng !#
• H2)'3'n(2
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
Al'$#$l T2!k *ain"lain
)atatan Per'em(anan Pasien Inisial Pasien: Tn+ ,
Tl-Bln-T#n Pr$(lem - Kejadian - Tinda'an Klinisi
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
A#)#32n5; *! g#k5n!(; D 40; A%3!)2.
D2!k#k!n )'&'32k(!!n !>53!532#&B
8708710 P!(2'n &'ng!!&2 '&!" !n ('(!k. H!(2 !! !>. g 708710
(''!" )'&>'32!n '3!)2 &'n#n/#kk!n n2!2 #3'#& 96:? &g7L !n
%3'!2n2n 9:0 &g7L: k!3'n! k!!3 ''k352 k!2#& < ?:96 &&57L
&!k! 2!k#k!n HD )#k# 0=.00 WI, ('!&! 4 /!&. T'3!)2 !ng
2>'32k!n '!). D2!k#k!n )'&'32k(!!n !>.)5( HD: "!(2n!
&'n#n/#kk!n n2!2 ''k352 k!2#&< 8:=8 &&57L &!k! )'&>'32!n
'3!)2 *! g#k5n!(: !%3!)2 !n D 40 2"'n2k!n.
4708710 P!(2'n &'ng!!&2 ('(!k: !n k!k2 >'ngk!k. T'3!)2 !ng 2>'32k!n
'!). D!n 2!k 2!k#k!n k53'k(2 "2)'3k!'&2
Tl-Bln-T#n Pr$(lem - Kejadian - Tinda'an Klinisi
?708710 P!(2'n &'ng!!&2 ('(!k: !n k!k2 >'ngk!k. T'3!)2 !ng 2>'32k!n
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
D2!k#k!n )'&'32k(!!n !>53!532#&
K!3'n! k5n2(2 )!(2'n (#!" &'&>!2k: &!k! )!(2'n 2)'3>5'"k!n
#n#k KRS "!32 2n2 -16.00 WI, 'ng!n %!!!n 3#2n HD ('(#!2
/!!. D!n 2k5n(#k!n k' 5k'3 535)'2 #n#k )'&'32k(!!n !(!&
#3! )!(2'n. T'3!)2 )'353! !ng 2>'32k!n (!! KRSB K5n22n 0:1? &g 1: A#)#32n5 100 &g 1 1 !n A&>35k(5 80 &g 8 1.
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
N5.DMKB 01 MRSB M!3' 010
KRSB 81 M!3' 010
In22! P!(2'nB Tn. W
U%,,7T2ngg2B 64 T!"#n741 kg
A!&!B M!!ng
Ri%a&at S$sial: ?am'esmas
Kelu#an Utama: S'(!k n!)!(
Dian$sa: *KD S!g' + HT + SO, -Short Of Breath
Ri%a&at Pen&a'it: G!g! g2n/! ('/!k 4 !"#n !ng !#:"2)'3'n(2 !n !(!& #3!. S'32ng &'3!(! n'32 '!)2 2!k&'&'32k(!k!n 232 k' 5k'3 ('/!k ? !"#n !ng !#.
Ri%a&at O(at: $
K')!#"!nB $
A'3g2B $
M'35k5k7Ak5"5B $
O>! T3!2(25n!B J!&# T3!2(25n!: /!&# g'n5ng ('2!) k!2 >!!n '3!(!'&!" !n )'g!$)'g!.
OT*B $
PROFIL PENGO,ATAN PADA SAAT MRS
O(at Rute D$sis Fre'
Tanal Pem(erian O(at
23 4 ? 6 = 9 80 81
O N!(!%!n#
= $ 10L 7&'n2 √ √ √ //
O = L 7&'n2 √ //
O 4 L 7 &'n2 √ // √ √ √ //
O 9 L 7&'n2 √ //
IFD NS 0.9 I 0 ( 7&'n2 √ √ √ √ √ // // √ √ //
D? I 0 ( 7&'n2 √ √ //
F#35('&2 I 40 &g 40$0$0 √ √ √ √ √ √ √ √ √ √
1
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR K5n22n P5 0:1? &g 1 √ √ √ √ √ √ √ √ √ √
A#)#32n5 P5 100 &g 1 1 √ √ √ √ √ // // // // √
A#)#32n5 P5 100 &g 1 √ √ √ √ //
*! g#k5n!( I 1 !&) 1 1 √ √ //
D 40 C( √ √ //
A%3!)2 S% 10 IU √ √ //
R!n222n I 00 &g 1 √ √ √ √ √ √ √ √ √ √
K!2!k' P5 ? g 1 1 √ √ √ √ //
A&>35k(5 P5 80 &g 8 1 √ √
H'&52!2(2( √ √ √
DATA K*INIK @ *ABORATORIUM SERTA DATA *AIN ANG MENDUKUNG Inisial Pasien: Tn+ ,
DATA K*INIK
NI*AI
NORMA
*
TG* BU*AN MARETC
8 4 ? 6 = 9 80 81
T'k!n!n !3!"-&&Hg
1807=0 140/8
0
150/
80
150/
80
140/7
0
140/7
0
140/7
0
130/8
0
N!2 -7M'n2 $1 =0 84 92 92 92 92 92 92
RR -7M'n2 $1 0 20 26 26 26 26 24 24
S#"# T#>#" -5* 86$8 36,3 8 8 8 86.4 86.4 86.= 86.= 86.6 8
18
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR H'&52!2(2( + + +
S'(!k + + + + + + + + + $
L'&!" + + + + + + + + $ $
,!#k $ $ $ $ $ $ $ $ + +
14
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR DATA K*INIK @ *ABORATORIUM SERTA DATA *AIN ANG MENDUKUNG Inisial Pasien: Tn+ ,
Data
*a($rat$rium
Nilai N$rmal MARET 31/1
33-5 35-5 30-5 36-5 37-5 51-5 5/-5
K''3!ng!n !$st
HD
HD
H'&5g5>2n 11$16 g7L <26 <2<
H'&!5k32 8?$4? 3125 3=20 3023
L'#k5(2 4000$10000 7#L 9000 9?00
T35&>5(2 1?0000$4?0000 7#L 000 16=000
U3'#& 10$4 &g7L ;620 0020 //=21 0021 5525
K3'!n2n 0:?$1:? &g7L ;231 5260 72=/ 0230 52=;
1?
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
16
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR DATA K*INIK @ *ABORATORIUM SERTA DATA *AIN ANG MENDUKUNG Inisial Pasien: Tn+ ,
Data
*a($rat$rium
Nilai
N$rmal
MARET 31/1
33-5 35-5 30-5 36-5 37-5 51-5 5/-5
K''3!ng!n !$st HD HD HD
N!32#& 18?$14?&&57L
/5= /0< /0= 140 186
K!2#& 8.?$?:8&&57L
0266 8:=8 4:98 8:= 5255
K532! 9=$106&&57L
108 //0 //0 106 /17
LED 0&&7/!&
6< <5
1
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
1=
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
LAPORAN KASUS
Inisial !asien: Dm *'C Berat Badan : =< ' Ginjal: *KD (
Umur : /=t# Tini Badan: " Hati : "
Kelu#an utama
,!!n >'ngk!k ('/!k &2ngg#: ('(!k ('/!k 1 &2ngg#: ,AK &'n#3#n
Kelu#an tam(a#an
,!!n g!! ('/!k "!32 !ng !# + &#!
Dian$sis:
*KD ( + An'&2! + A(25(2( M'!>52k -1?78
*KD ( + N'C352( ,2!'3! + U'&! + A(%2'( '.%. H2)5!>#&2n -1=78
Ri%a&at Pen&a'it:
$
19
Tanal
Pr$(lem- Kejadian- Tinda'an Klinisi
7/17/2019 kasus 1.doc
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR Ri%a&at !en$(atan
O(at D$sis Indi'asi
T2!k !! !!
Aleri : " Ke!atu#an P!#" O(at"$(atan tradisi$nal $Mer$'$' $ OT) $Al'$#$l $ *ain"lain $
,'3!(!3k!n "!(2 assesment !)5'k'3 'ng!n k'#!3g! )!(2'n
)atatan Per'em(anan
Pasien
DATA K*INIK
Data Klini' Maret 31/1
/0 /6 /7 /< /;
KU L L L L LTD 1?0790 1?07110 14070 1?07100 107=0
N!2 =0 = 9 =0 =0RR = = 6 4 4G*S 4$?$6 4$?$6 4$?$6 4$?$6 4$?$6S'(!k + + + P!n!( $ $ $ $ 86:?
Tanal Pr$(lem- Kejadian- Tinda'an Klinisi
1?78 P!(2'n &!(#k IRD 'ng!n k'#"!n >!!n >'ngk!k ('/!k &2ngg#: ('(!k ('/!k 1&2ngg#: ,AK &'n#3#n: 2('3!2 g!! ('/!k "!32 !ng !#: >'#& )'3n!" %#%2!3!" ('>'#&n!. K5n2(2 #&#& )!(2'n '&!". D2!gn5(2( !! &!(#k !!!"*KD ( -S*3 )!(2'n 16:4 *3* < < ?:1 1? *KD ( : !n'&2! -H><6:;R,*<:18; H%<1=:?: !n !(25(2( &'!>52k -)H !3!"< :; H*O8<?:1; )*O<18: )O<16?. P!(2'n /#g! &'ng!!&2 "2)'3k!'&2 -K +<?:6= !n"2)5!>#&2n -!><:8. T'k!n!n !3!" )!(2'n 1?0790 &&Hg: !n &'n#n/#kk!ng'/!! 2nC'k(2 -W,*<16.100; RR<=
T2n!k!n k2n2(2B
!(25(2( &'!>52k k53'k(2 'ng!n N!32#& >2k!3>5n!
!n'&2! 3!nC#(2 PR* !n !(!& C5!
"2)5!>#&2n 23'(')k!n !>#&2n ->'#& '3!k(!n! &'n!)! !>#&2n '3k!2 )'ng#3#(!n !&2n2(3!(2 )!(2'n J!&k'(&!(
&'ng5n35 'k!n!n !3!" !g!3 '3%!)!2 !3g' TD *KD 1807=0 &&Hg !&52)2n
'3!)! g'/!! 2nC'k(2 )'32n!" 5k'3 #n#k k##3
&'ng!!(2 "2)'3C5(C! !ng #&#&n! '3/!2 )!! )!(2'n *KD *!*O 8
1678 KU )!(2'n '&!" !n TD &!(2" 1?07110 &&Hg. K5n2(2 !(25(2( &'!>52k&#!2 !)! '3!!(2 -)H<:8; H*O8<9:; )*O<1:=: )O<104:?. InC#( !>#&2n(#!" !)! 2>'32k!n. T'3!)2 !2n '!).
178 KU )!(2'n '&!" !n TD 14070 &&Hg. K5n2(2 !(25(2( &'!>52k '3#!ngk'&>!2 -)H !3!"< :19; H*O8<6:1; )*O<16: )O<11 2>'32k!nD40+2n(#2n IU !n *! g#k5n!(. T!n! 2nC'k(2 &!(2" '3/!2 -W,*<18.600;
RR<6; n!2<9 2>'32k!n !n2>252k '&)232( %'C32!5n !ng 2!k&'&>##"k!n adjustment dose #n#k )!(2'n *KD. A(!& C5! (#!" 2!k2>'32k!n k!3'n! n2!2 M* !ng n53&! -=?:. *!*O8 2"'n2k!n k!3'n! k!!3C5(C! n53&! -8:1. K!!3 !>#&2n )!(2'n k'&>!2 3'n!" -: ('"2ngg! 5k'3&'3'(')k!n !>#&2n ->'#& '3!k(!n! &'n!)! !>#&2n '3k!2 )'ng#3#(!n!&2n2(3!(2 )!(2'n J!&k'(&!(.P!! &!!& "!32 2!k#k!n "'&52!2(2( !n )!(2'n &'ng!!&2 k'/!ng )5(HD 2>'32k!n 2n/'k(2 2!')!&. P'&'32k(!!n ,GA &'n#n/#kk!n >!n!k k'&!/#!n-)H< :8=; H*O8<11:=; )*O<0: )O<?.
1=78 KU )!(2'n '&!": TD 1?07100 2>'32k!n !&52)2n !n C#35('&2 -/#g! #n#k&'ng!!(2 #'&. K5n2(2 "2)'3C5(C! '3#!ng -:0. InC#( !>#&2n (#!" !)!
0
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR U'& + + + + +K'/!ng-)5( HD
+
1
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
DATA *ABORATORIUM
DATA *ABORATORIUMNI*AI
NORMA*
MARET 31/1
/0 /6 /7 /<
S*3 0:6 1:1 16:4 16:9,UN ? 8 194 80A>#&2n 8:= ?:4 :8 :W,* 4:? 10:? 16:1 18:6R,* 4 6 :18 :?H> 11 1= 6: 6:=9H*T 8? 60 1=:? 19:8M* =0$90 = =?:AST -SGOT ? 84 1= ALT -SGPT 11 60 1? 0G#k5(! !%!k 00 9? 16,223#>2n 5! 0 1 0:4,223#>2n 23'k 0 0:8 0:0HDL 4? &g7 1LDL 60 1=0 &g7 18U32% !%2 4:0 =:? &g7 14:*$ 9 108 116 10: 111:= 104:9 N!+ 186 144 18:4 18=:6 18?:? 188:9K + 8:= ? ?:6= ?:64 ?:?9 8:=6
*!+
=:1 10:4 := : =:= ?:8P"5()"! 8:0 4:? 8:1 :0
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
Hasil *a($rat$rium
T!ngg! J'n2( P'&'32k(!!n H!(2
1?78 010 F55 T53!k( *53 !n )#&5 2!k !&)!k k'!2n!n
1?78 010 USG !>5&'n *KD N'C322( >2!'3!
H235n'C35(2( 32ng!n >2!'3!
A(%2'(
EC#(2 )'#3! k!n!n
H')!372'n7G,7)!nk3'!( 2!k !&)!kk'!2n!n
BGA Nilai N$rmal
Maret 31/1
/0 /6/7
Pre HD
/7
P$st HD/<
)H -:8? :4? : :8 :19 :8= :89 )*O -8? 4? 18 1:= 16 0 ? )O -=0 10 16? 104:? 11 ? 8H*O8 - = ?:1 9: 6:1 11:= 1?:1
,E -$ + $1:== $:8 $1:09 $4:1= $0:9
8
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
Urinalisis Nilai N$rmal
Maret 31/1
K$mentar dan Alasan/0 )H 4:6 = ?:? P!! *KD '3/!2 k'>5%53!n g5&'3##( )!!
(!! C23!(2: ('"2ngg! )35'2n !ng >'3&5'k# >'(!3 !)! 55( &'n#/# #32n. T2!k '3!)!g#k5(! !!& #32n &'n#n/#kk!n >!"! )!(2'n2!k &'n'32! DM -(!!" (!# C!k53 2n2(2(2!(2*KD
G#k5(! $ $,223#>2n $ $K'5n $ $P35'2n $ 8+L'#k5(2 $ $
N5. DMK B 11088106
MRS B
In2(2! )!(2'nB D&
U%,,7T2ngg2B 14"7 4= kg7 $
A!&! B Ng#!"!n
S!#( B JPS
K'#"!n #!&!B ,'ngk!k ('#3#" #>#" + &2ngg# ('(!k
D2!gn5(! B *KD ( + An'&2! +A(25(2( M'!>52k -1?78
*KD ( + N'C352( ,2!'3! + U'&! +A(%2'( '.%. H2)5!>#&2n -1=78
R2!! )'n!k2B $
R2!! 5>! B $
K')!#"!n B Q
A'3g2 B $
M'35k5k B $
Ak5"5 B $
4
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PRAKTEK KERJA PROFESI RUMAH SAKIT
PROGRAM PENDIDIKAN PROFESI APOTEKER PERIODE 90
FAKULTAS FARMASI UNAIR
PROFI* PENGOBATAN PADA SAAT MRS
O(at Rute Reimentasi
Tanal Pem(erian O(at
/0 /6 /7/
<
/;
N!$>2k!3>5n! 2 100 &7 6 /& Q
*! G#k5n!( 2 10 & Q Q
D40B2n(#2n U 2 ? %% Q
*!*O8 )5 8 ?00&g Q Q
T3!n(C#(2 PR* 2 1 >!g Q Q Q Q
A(!& C5! )5 1 1 &g Q Q Q
A&52)2n )5 ?&g$0$0 Q Q QQ
F#35('&2 2 4 0 &g Q
A>#&2n 0 2 100 %% Q Q
*'C32!5n 2 1 g Q QQ
D2!')!& 2 ? &g Q
K''3!ng!nB T!ngg! 178 HD
?
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