laporan jaga icu sebelum 15 jan 2015

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

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

ZK/L/47 thstatus epileptikus ec susp SOL intrakranial+ CVD SH

Dr. Deiby Wuisan, SpAn

Simone

131-100

55-98

80-92

34,0-39,3

15-28

99-100%

E3M4V2

Konj. Anemis +/+ Sklera ikterik -/-

SI-II n regular, bising -, murmur -

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

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

PO2/FIO2 466,3

1450 cc650 cc

800 cc

14 Januari 2015 (Hari Perawatan ke 13)

pH 7,478/pCO2 37,3 /pO2 149,2/HCO3- 27,3/ BEecf -3,4/ SO2 98,8/ Hb 9,8/ Hct 29

Albumin 3 x 2 caps

KSR 3 x 1 tab

Allopurinol 200 mg 0 - 0 - 1

Bromocriptin 5 mg 2-1-0Simvastatin 0 - 0 -1

penitoin 2 x 100 mg caps

new diatabs 3 x 1

Asam Folat 2 x 1 tab

citicolin 2 x 500 inj

Ranitidin 2 x 50 injNebulizer 3x1

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 Frontobasal + SAH

dr. Deiby Wuisan, Sp.An

Simone

104-125

56-79

50-82

36,4-36,8

13-24

99-100%

E2M4V1



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


PO2/FIO2 681,2

2550 ccmin 280 cc

2830 cc


pH 7,507/pCO2 37,7 /pO2 170,3/HCO3- 30,1/ BEecf 6,8/ SO2 99,3/ Hb 10,9/ Hct 33



Cenftriaxone 2x1Ranitidine 2x50

Brain act 2x500

Asam tranexamat 3x500

Vit c 2x200

paracetamol drips 3x1/2

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

MS/L/35 thn

Vulnus Ictum Penetrasi Abdomen

dr. Deiby Wuisan, Sp.An

Simone

120-199

90-136

80-149

35,5-37,5

21-34

86-99%

on midazolam





PO2/FIO2 138,6

2050 cc850 cc

1200 cc


pH 7,468 /pO2 69,3/HCO3- 37,8/ BEecf 13,8/ SO2 81,3,6/ Hb 9,3/ Hct 28



Merophenem 3x 1Ranitidine 2x50

Vit c 2x200

Tramadol 3x1 drips

Bisolvon 3 x1

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

ID/L/55 thn

Post pionefrosis+nefrolithiasis sinistra

dr. Wahyudin Suleman, M.Kes, SpAn

Patricia

132-167

89-115

90-160

36,0-37,5

16-19

99-100%

E4M6V5

Konj. Anemis -/- Sklera ikterik -/-




PO2/FIO2 227,6

1350 cc750 cc

600 cc

0,38 cc/kgBB/ 24 jam

750 cc

123,3/3,71/109,7


pH 7,376/pCO2 35,5 /pO2 227,7/HCO3- 21,3/ BEecf -4,4/ SO2 99/ Hb 11,9/ Hct 36



Ceftriaxone 2 x 1Metronidazole 3 x 500

Ranitidin 2 x 1

Keterolac 3 x 1

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

FW/P/44 thn

Ca Mammae Dextra post Neoadjuvant

dr. Wahyudin Suleman, M.Kes, SpAn

Patricia

112-140

68-78

75-89

35,5-37,8

14-18

99-100%

E4M6V5

Konj. Anemis -/- Sklera ikterik -/-




PO2/FIO2 502,0

1050 cc1050 cc

450 cc

0,31 cc/kgBB/ 24 jam

1050 cc

121,3/3,73/109,5


pH 7,497/pCO2 27,8 /pO2 160,6/HCO3- 21,7/ BEecf -1,7/ SO2 98,9/ Hb 8,7/ Hct 26



Ceftriaxone 2 x 1 Ranitidin 3 x 1

Tramadol 3 x 1

As.Traxenamat 3 x 500

Vit C 1 x 1

laporan jaga icu sebelum 15 jan 2015

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