lembar observasi tn e

5
Lembar Observasi Tgl : 12 April 2015 Nama : Tn. E Tgl masuk : 09 April 2015 Usia : 63 thn Hari Ke : BB : ± 60 kg Bed : 5 No. Medrek : 0001443246 HR Suhu TD MAP RR EKG SR SR SR SR SR SR SR SR Sat O 2 GCS (E/M/V) 4/6/5 4/6/5 4/6/5 4/6/5 4/6/5 4/6/5 4/6/5 4/6/5 Kesadaran CM CM CM CM CM CM CM CM I n t a k e CM CA CM CA CM CA CM CA CM CA CM CA CM CA CM CA Transfusi - - - - - - - - - - - - - - - - Makanan (Oral) Parenteral : CM/CA CM CA CM CA CM CA CM CA CM CA CM CA CM CA CM CA RL Manitol Jml 1 jam/Kumulatif

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Lembar ObservasiTgl: 12 April 2015Nama: Tn. E

Tgl masuk: 09 April 2015Usia: 63 thn

Hari Ke: BB: 60 kg

Bed: 5No. Medrek: 0001443246

HR

Suhu

TD

MAP

RR

EKGSRSRSRSRSRSRSRSR

Sat O2

GCS (E/M/V)4/6/54/6/54/6/54/6/54/6/54/6/54/6/54/6/5

KesadaranCMCMCMCMCMCMCMCM

Int akeCMCACMCACMCACMCACMCACMCACMCACMCA

Transfusi----------------

Makanan (Oral)

Parenteral : CM/CACMCACMCACMCACMCACMCACMCACMCACMCA

RL

Manitol

Jml 1 jam/Kumulatif

OutputUrine/feses

NGT/MAAGSLANG

IWL

Jml 1 jam/Kumulatif

Keseimbangan Cairan

Lembar ObservasiTgl: 12 April 2015Nama: Tn. E

Tgl masuk: 09 April 2015Usia: 63 thn

Hari Ke: BB: 60 kg

Bed: 5No. Medrek: 0001443246

14.0015.0016.0017.0018.0019.0020.0021.00

HR74 x/m63 x/m64 x/m70 x/m63 x/m65 x/m71 x/m83 x/m

Suhu35,83636,13636,136,136,236,2

TD155/116146/67143/67148/79137/66148/65144/63149/72

MAP829092898997110

RR3619212320201921

EKGSRSRSRSRSRSRSRSR

Sat O298991009899989898

GCS (E/M/V)4/6/54/6/54/6/54/6/54/6/54/6/54/6/54/6/5

KesadaranCMCMCMCMCMCMCMCM

Int akeCMCACMCACMCACMCACMCACMCACMCACMCA

Transfusi----------------

Makanan (Oral)2007030070200

Parenteral : CM/CACMCACMCACMCACMCACMCACMCACMCACMCA

RL838383838383

Manitol100100

Jml 1 jam/Kumulatif283/283100/383153/536383/919153/107283/115583/1238300/1538

OutputUrine/feses--200---400

NGT/MAAGSLANG

IWL2525252525252525

Jml 1 jam/Kumulatif25/2525/50225/27525/30025/32525/350425/77525/800

Keseimbangan Cairan+258+333+261+619747

Lembar ObservasiTgl: 19 September 2013Nama: Tn. D

Tgl masuk: 10 September 2013Usia: 28 thn

Hari Ke: 10BB: 50 kg

Bed: 4No. Medrek: 13061027

07.0008.0009.0010.0011.0012.0013.0014.00

HR8383878687898995

Suhu33,833,133,133,133,2383835

TD117/78111/83115/61107/75107/75109/76109/76109/75

MAP91927985.685,6878786

RR1414282825252510

EKGSRSRSRSRSRSRSRSR

Tipe ventilatorSIMVRR 14PEEP 5FiO2 45%SIMVRR 14PEEP 5FiO2 45%SIMVRR 7PEEP 5FiO2 50%SpontanPEEP 7FiO2 50%SpontanPEEP 7FiO2 50%SpontanPEEP 7FiO2 50%SpontanPEEP 7FiO2 50%SIMVRR 10PEEP 5FiO2 50%

Sat O299%99%99%100%100%100%100%99%

GCS (E/M/V)3/4/T3/4/T2/4/T2/4/T3/4/T3/4/T3/4/T3/4/T

KesadaranSomnolen SomnolenSomnolenSomnolenSomnolenSomnolenSomnolenSomnolen

Int akeCMCACMCACMCACMCACMCACMCACMCACMCA

Transfusi

Makanan (Oral)180150

Parenteral : CM/CACMCACMCACMCACMCACMCACMCACMCACMCA

NaCl 0.9%10440104302801502013010120201003070

Jml 1 jam/Kumulatif10/10190/200280/48020/50010/510170/68030/710

OutputUrine/feses4522010090903375

NGT/MAAGSLANG--------

IWL21212121212121

Jml 1 jam/Kumulatif6266/62241/303121/424111/535111/64654/70096/796

Keseimbangan Cairan-52-93+56-35-136-20-86

Lembar ObservasiTgl: 20 September 2013Nama: Tn. D

Tgl masuk: 10 September 2013Usia: 28 thn

Hari Ke: 11BB: 50 kg

Bed: 4No. Medrek: 13061027

14.0015.0016.0017.0018.0019.0020.00

HR93889091969191

Suhu3433,834,13434,334,333,8

TD100/6498/62102/68102/6897/61102/64119/76

MAP767477

RR14111415151515

EKGSRSRSRSRSRSRSR

Tipe VentilatorSIMV RR 5PEEP 8FiO2 30%SIMV RR 5PEEP 8FiO2 30%SIMV RR 5PEEP 8FiO2 30%SIMV RR 15PEEP 8FiO2 30%SIMV RR 15PEEP 8FiO2 30%SIMV RR 15PEEP 8FiO2 30%SIMV RR 15PEEP 8FiO2 30%

Sat O2100%98%98%98%98%98%98%

GCS (E/M/V)2/4/T2/4/T2/4/T2/4/T2/4/T2/4/T2/4/T

KesadaranSomnolen SomnolenSomnolenSomnolenSomnolenSomnolenSomnolen

Int akeCMCACMCACMCACMCACMCACMCACMCA

Transfusi

Makanan (Oral)150

Parenteral : CM/CACMCACMCACMCACMCACMCACMCACMCA

NaCl 0.9%102505020010190901005050203030500

Jml 1 jam/Kumulatif10/79050/84010/850240/109050/114020/116030/1190

OutputUrine6585601104015

NGT/MAAGSLANG-------

IWL21212121212121

Jml 1 jam/Kumulatif86/768106/87481/955131/108661/114721/116836/1204

Keseimbangan Cairan+22-34-105+4+7-8-14