I.

PELAKSANAAN DAN EVALUASI KEPERAWATAN

JAM TINDAKAN DIAGNOSA KEPERAWATAN PARAF PERAWAT

HARI/TGL

Kamis 10-10-13

14.00 T:

Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 56 x/ menit, TD 151/70 mmHg, MAP 75 mmHg , kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 796, out put 1410, balance -614 Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 65 x/ menit, TD 135 /91 mmHg, MAP 102 mmHg , RR 22, Suhu 36,6 kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1093, out put 1715, balance -622. Memberikan manitol 200 cc Diuresis 600 cc Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 72 x/ menit, TD 143 /94 mmHg, MAP 105 mmHg , Suhu 36,5, RR 18 kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1136, out put 1840, balance -704. Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 97x/ menit, TD 205 /117 mmHg, MAP 102 mmHg , Suhu 37, RR 30, kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1233, out put 2215, balance -982.

E:

15.00 T:

E:

15.00 T: E: 16.00 T:

E:

17.00 T:

E:

HARI/TGL

JAM

TINDAKAN

DIAGNOSA KEPERAWATAN

PARAF PERAWAT

17.00 T:

Memberikan injeksi kalnek 1 ampul/ IV, Vit K 1 ampul/ IV, penytoin 1 ampul/ IV Perdarahan drain (+) 50 cc/ 8 jam Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 87x/ menit, TD 135 /95 mmHg, MAP 102 mmHg , Suhu 37,2 , RR 18, kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1280, out put 2330, balance -950. Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 68x/ menit, TD 155/93 mmHg, MAP 110 mmHg , Suhu 37,2 , RR 16, kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1550, out put 2655, balance -1105. Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 68x/ menit, TD 181/95 mmHg, MAP 125 mmHg , Suhu 37 , RR 21, kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1580, out put 2730, balance -1150. Observasi TTV, Haeodinamik, Status kesedaran, ventilasi , intake dan out put HR 68x/ menit, TD 181/95 mmHg, MAP 125 mmHg , Suhu 37 , RR 21, kesadaran DPO. Mode ventilator CPAP, PEEP 5, saturasi 99% FiO2 45%, TV 450, intake 1580, out put 2730, balance -1150. Memberikan injeksi ranitidine 1 ampul/ I V dan keterolac 1 ampul / IV Cairan dekomresi warna coklat kehitaman, volume 30 cc/ 8 jam

E: 18.00 T:

E:

19.00 T:

E:

20.00 T:

E:

21.00 T:

E:

21.05 T:

E: