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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

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Al'$#$l T2!k *ain"lain

)atatan Per'em(anan Pasien Inisial Pasien: Tn+ ,

Tl-Bln-T#n Pr$(lem - Kejadian - Tinda'an Klinisi

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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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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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N5.DMKB 01 MRSB M!3' 010

KRSB 81 M!3' 010

In22! P!(2'nB Tn. W

U&#37,,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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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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FAKULTAS FARMASI UNAIR H'&52!2(2( + + +

S'(!k + + + + + + + + + $

L'&!" + + + + + + + + $ $

,!#k $ $ $ $ $ $ $ $ + +

14

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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?

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16

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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

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1=

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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

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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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FAKULTAS FARMASI UNAIR U'& + + + + +K'/!ng-)5( HD

+

1

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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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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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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&#37,,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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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

?

kasus 1.doc

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