LOGO

LAPORAN PASIEN ICU

27 April 2015

1. Ny. N/81 th/D/ Post Laparotomy a.i Ileus Obstruksi e.c

Susp. Keganasan + Electrolyte Disturbance + AKI +
Hypoalbuminemia
Objektif

Assesment

CNS : komposmentis
-

CVS TD : 160/80 mmHg

Support: -

HR : 104x/m
CVP :
RR : 17 x/mnt T : 36.7 C
o

SpO2 :100% terhubung

ventilator mode CPAP Pasb 10
FiO2 50% PEEP 5
GIT : NGT (+)

GUT : Kateter (+)

Post Laparotomy a.i. Ileus

Obstruksi e.c. Susp. Keganasan
Electrolyte Disturbance
AKI
Hypoalbuminemia

Planning

F:
Enteral :
D5% 6x25
Nephrisol 6x100- 150 cc
Parenteral :
Tutofusin ops 600
A : Tramadol 3 x 50 mg
Pronalges supp 2x2

Lab :
Hb: 13,1 / Leukosit : 23.400 / Ht : 41
Trombosit : 256.000 / GDS: 134 / Ureum:
66 / Kreatinin: 1.4 / Ca: 6,0 / Na :141 / K:
3,2 / Cl : 103

S: -

AGD :
pH 7.46 / PCO2 53 mmHg / PO2125
mmHg / HCO3- 37,7 mmol / L / BE 12,0
mmol/L / SO2 99%

G:-

T: H : Up 30
U : Omeprazol 1x 40 mg

Th:
Enteral : Parenteral :
- Meropenem 3 x 1 gr
- Metronidazole 3 x 500 mg
- Asam traneksamat 3x500 mg
- Vit K 3x10 mg
- Vit C 2x200 mg
- Dycinone 3 x 200 mg
- Lasix 3 x 1 amp -> titrasi 5mg / jam
- Tamoliv 1000 mg

2. Tn. RA/31 th/D/ Post Laparotomi a.i Peritonitis Difus e.c Abses Hepar +
AKI+Electrolyte Disturbance + Hypoalbuminemia
Objektif

Assessment

CNS : kesadaran CM

CVS TD : 126/76mmHg
Support -

- Post Laparotomy a.i. Peritonitis

Difus e.c. Abses Hepar
- AKI
- Electrolyte Disturbance
- Hypoalbuminemia

Planning
F:
Enteral : sementara puasa
Parenteral: Tutofusin Ops 500cc/24
jam, Gelofusin 200 cc, RL 500 cc, D40%
3flc, Plasbumin 25% 100cc, Ca
Gluconas 2 gr
A : Tramadol 2 x 100 mg

HR : 65x/mnt
CVP :
RR : 12 x/mnt T: 36,5 C
SpO2 : 100% terhubung
ventilator mode BIPAP Pins
18 Pasb 13 PEEP 5 FiO2
40%

GIT : NGT (+)

GUT : Kateter (+)

S:Lab:
Hb: 12,3 / Leukosit: 14.200 / Ht:
37% / Trombosit: 142.000 / GDS:
47 / Ureum: 255 / Kreatinin: 2,8 /
Ca: 6.5 / Total protein 5,4 /
Albumin 1,8 / Globulin 3,6 /
Bilirubin total: 1,6 / SGOT: 305 /
SGPT: 167
AGD :
pH 7,19 / PCO2 40 / PO2 228 / BE
-12,3 / HCO3- 15,3 / SO2100%

T:H : Up 30
U : OMZ 2x40 mg
G:-

Th:
-

Meropenem 3x1 gr
Vit C 3 x 200 mg
Lasix 2 x 1 amp
Metronidazole 3 x 500 mg
Ondansentron 3 x 1 amp

3. Ny.SA/38 th/ D/ Post OP SC e.c PEB & ALO + Respiratory Failure e.c ALO +
CVS disturbance + Electrolyte Disturbance + Hypoalbuminemia
Objektif

Assessment

CNS : komposmentis

CVS TD : 136/90 mmHg

Support -

Post OP SC e.c PEB + ALO

Respiratory Failure e.c ALO
CVS Disturbance
Electrolyte Disturbance
Hypoalbuminemia

Planning
F:
Enteral : Entramix 6x100 cc
Parentaral :
-Tutofusin ops 1500 cc/24 jam
- KCl 70 mEq
- Ca Glukonas 2 gr
- Plasbumin 25% 100cc
- FFP 1 unit
A : Tramadol 3x50 mg

HR : 95 x/mnt
CVP : RR : 12 x/mnt T : 37,3 C
SpO2 : 100 % terhubung
ventilator mode BIPAP Pinsp
17 Pasb 12 PEEP 5 FiO2
50%
GIT : NGT (+)

GUT :kateter (+)

S:Lab:
Hb: 11,4 / Leukosit: 18.360 / Ht:
35% / Trombosit: 224.000 / GDS:
120 / Ureum: 123 / Kreatinin: 2,8 /
Na: 135 / K: 4,9 / Cl: 105 / Total
protein: 5,6 / Albumin: 3,3 /
Globulin: 2,3

T: H : Up 30
U : OMZ 2x40mg
G:-

Th :
Enteral : KSR 3 x 2tab, inpepsa syr 3 x 10 cc,
zitromax 1 x 750 mg, metyldopa 3 x 500 mg,
diamox 3 x 1 amp
Parenteral : Ceftriakson 2x1 gr, Azitromisin 1
x750 mg, Vit C 2x400 mg, Ondansentron 3 x4
mg, Lasix 1 x 1 amp, Flumucyl 3 x 1 amp,
Naired 3 x 0.3 cc, Metylprednisolon 2 x 125mg,
Tamoliv

4. Ny.YK/61 th/D/ Post OP Craniectomy e.c. SDH + Severe Hypertension +

Electrolyte Disturbance
Objektif

Assessment

CNS : kesadaran CM GCS 15

CVS TD : 123/79 mmHg

Support -

- Post OP Craniectomy e.c. SDH

- Severe Hypertension
- Electrolyte Disturbance

Planning
F:
Enteral : Parenteral: Tutofusin ops 2000 / 24
jam, Ca Glukonas 2gr
A:-

HR : 120x/mnt

S:-

CVP :

T:-

RR : 16 x/mnt T: 36,7 C
SpO2 : 100% terhubung
ventilator mode BIPAP Pins
17 Pasb 12 PEEP 5 FiO2
40%

GIT : NGT (+)

GUT : Kateter (+)

Lab:
GDS: 128 / Ca: 7.5 / Na: 140 K /
3,7 / Cl 107 / Ureum: 50 / Kreatinin:
1.5
AGD :
pH 7,44 / PCO2 45 / PO2 96 / BE
3.9 / HCO3- 30,6 / SO2 98%

H : Up 30
U : OMZ 1 x 40mg
G:-

Th:
Enteral:
Amlodipin tab 10 mg 1x1
Captopril tab 25 mg 3 x 1 (lihat T-nya)
KSR 3 x 1 tab
Parenteral:
Ceftriaxone 2 x1 gr (H2)
Vit C 2 x 100
Vit K 3 x 10 mg
Decynon 3 x 200 mg
Asam Traneksamat 3 x 1 gr
Fluimucyl 3 x 1gr

5. Tn. MS/67 th/D/ Stroke Infark + PPOK eksaserbasi akut + Electrolyte

Disturbance + Hipertensi
Objektif
Assessment
Planning
CNS : kesadaran somnolen

CVS TD : 150/64 mmHg

Support -

- Stroke Infark
- PPOK Eksaserbasi Akut
- Electrolyte Disturbance
-Hipertensi

F:
Enteral : D5% 6x25-50 cc, Mc Entramix
Parenteral: Triofusin E1000 1500cc/24
jam, Ca Gluconas 3 gr
A:-

HR : 34x/mnt

S:

CVP :

T:-

RR : 26 x/mnt T: 37,9 C
SpO2 : 100% terhubung
ventilator mode CPAP PAsb
10 PEEP 5 FiO2 50%
GIT : NGT (+)

GUT : Kateter (+)

Lab:
Ureum: 21 / Kreatinin: 1,0 / Ca:
6,4 / Na: 136 K / 4,0 / Cl 108
AGD :
pH 7,43 / PCO2 41 / PO2 96 / BE
2,7 / HCO3- 27,2 / SO2 98%

H : Up 30
U : OMZ 2x40 mg
G:Th:
Enteral : Parenteral:
Meropenem 3x1 gr (H3)
Nairet 3 x 0.3 cc
Brain act 2 x 1 gr
Alinamin F 1 x 25mg
Vit C 2x400 mg
Neurotam drip 12mg/hari
Flumucyl 3 x 1amp
Azitromax 1 x 750mg (H3)
Lain-lain:
Nebulizer 6x1
Pulmicort + combivent + bisolvon

LOGO

Thank You