TANGGAL

08/01/16

S
-

KU: sedang, GCS E4VxM6

Post

ICU

TD: 116/700 mmHg

Laminectomy

Bedah saraf

N: 126 x/menit

Fusi

1. Infus

RL

aminofluid 2:1 / 24

stabilisasi jam
2. Diet sonde 5x 200
RR: ventilator SMV 10 VC
I-II
ai
ml / 24 jam
x/menit, sat 90%
Tetraplegi
ec
3. Infus PCT 1 g/24
SpO2 : 100%
Spondilolithesis
jam
VC
I-II,
fr4. Inj
cerneva
1
Motorik :

0 0
0 0

odontoid

post amp/24 jam

5. Mobilisasi
miring
tracheostomi
ai
kanan-kiri, duduk
prolong ET
ROM pasif
6.Perawatan

Leher:
terpasang tracheostomi
10/01/16

KU: sedang, GCS E4VXMX

Post

ICU

TD: 102/66 mmHg

Laminectomy

Bedah saraf

N: 106 x/menit

Fusi

Tracheotomy
7.Fisioterapi
1. Infus
RL

aminofluid 2:1 / 24

stabilisasi jam
2. Diet sonde 5x 200
RR: ventilator SMV 10 VC
I-II
ai
ml / 24 jam
x/menit, sat 90%
Tetraplegi
ec
3. Infus PCT 1 g/24
SpO2 : 100%
Spondilolithesis
jam
Motorik :
0 0
VC
I-II,
fr4. Inj Meropenem 1
0 0

odontoid

post g/8 jam

5. Inj cernevit : vit c :
tracheostomi
ai
bio atp = 1:1:1
prolong ET
dalam 100cc NaCl
0.9 %
6. Mobilisasi

Leher:
terpasang tracheostomi

miring

kanan-kiri, duduk
ROM pasif
7.Perawatan

11/01/16

KU: sedang, GCS E4VXMX

Post

Tracheotomy
8.Fisioterapi
1.Infus
RL

ICU

TD: 90/54mmHg

Laminectomy

aminofluid 2:1 / 24

Bedah saraf

N: 94x/menit

Fusi stabilisasi

RR: ventilator SMV 10 VC I-II ai

ml / 24 jam
3. Infus PCT 1 g/24

x/menit, sat 90%

Tetraplegi ec

SpO2 : 100%

Spondilolithesis
VC I-II, fr

Motorik :

jam
2. Diet sonde 5x 200

jam
4. Inj cernevit : vit c :

0 0

odontoid post

bio

0 0

tracheostomi ai

dalam 100cc NaCl

prolong ET

atp

0.9 %
5. Mobilisasi

1:1:1

miring

kanan-kiri, duduk

Leher:

ROM pasif

terpasang tracheostomi

6.Perawatan

13/01/16
Bedah saraf

Tracheotomy
7.Fisioterapi
1. Infus
RL

KU: sedang, GCS E4VXMX

Post

TD: 103/62 mmHg

Laminectomy

N: 89 x/menit

Fusi

RR: ventilator SMV 10 VC

aminofluid 2:1 /

stabilisasi
I-II

ai

x/menit, sat 90%

Tetraplegi

SpO2 : 100%

Spondilolithesis

Motorik :

0 0

VC

I-II,

0 0

odontoid
tracheostomi
prolong ET

Leher:
terpasang tracheostomi

ec

24 jam
2. Diet sonde 5x 200
ml / 24 jam
3. Infus PCT 1 g/24

jam
fr 4. Inj Meropenem 1

post
ai

g/8 jam
5. Inj cernevit : vit
c : bio atp = 1:1:1
dalam

100cc

NaCl 0.9 %
6. Mobilisasi miring
kanan-kiri, duduk
ROM pasif
7. Perawatan
Tracheotomy
8. Fisioterapi

16/01/16

KU: sedang, GCS E4VXMX

Post

ICU

TD: 103/64 mmHg

Laminectomy

Bedah saraf

N: 94 x/menit

Fusi

RR: ventilator SMV 10 VC

1. Infus
stabilisasi
I-II

ai

Tetraplegi

SpO2 : 100%

Spondilolithesis
0 0

VC

I-II,

0 0

odontoid
tracheostomi

aminofluid 2:1 /

x/menit, sat 90%

Motorik :

RL

ec

24 jam
2. Diet sonde 5x 200
ml / 24 jam
3. Infus PCT 1 g/24

jam
fr 4. Inj Meropenem 1

post
ai

g/8 jam
5. Inj

cernevit

1amp / 24 jam
6. Bio ATP 3 x 1
7. Mobilisasi miring

prolong ET
Leher:
terpasang tracheostomi

kanan-kiri, duduk
ROM pasif
8. Perawatan

20/01/16

Tracheotomy
9. Fisioterapi
1. Infus
RL

KU: sedang, GCS E4VXMX

Post

ICU

TD: 106/68 mmHg

Laminectomy

Bedah saraf

N: 101 x/menit

Fusi

stabilisasi

0 0

VC

I-II,

0 0

odontoid

aminofluid 2:1 /

24 jam
2. Diet lunak
RR: ventilator SMV 10 VC
I-II
ai
3. Infus PCT 1 g/24
x/menit, sat 90%
Tetraplegi
ec
jam
SpO2 : 100%
Spondilolithesis
4. Inj Meropenem 1
Motorik :

tracheostomi
prolong ET
Leher:

fr
post
ai

g/8 jam
5. Inj

cernevit

1amp / 24 jam
6. Bio ATP 3 x 1
7. Mobilisasi miring
kanan-kiri, duduk

terpasang tracheostomi

ROM pasif
8. Perawatan

28/01/16

KU: sedang, GCS E4VXMX

Post

Tracheotomy
9. Fisioterapi
1. Infus
RL

ICU

TD: 106/68 mmHg

Laminectomy

aminofluid 2:1 /

Bedah saraf

N: 101 x/menit

Fusi

stabilisasi

0 0

VC

I-II,

0 0

odontoid

24 jam
2. Diet lunak
RR: ventilator SMV 10 VC
I-II
ai
3. Infus PCT 1 g/24
x/menit, sat 90%
Tetraplegi
ec
jam
SpO2 : 100%
Spondilolithesis
4. Inj Meropenem 1
Motorik :

tracheostomi
prolong ET
Leher:
terpasang tracheostomi

fr
post
ai

g/8 jam
5. Inj

cernevit

1amp / 24 jam
6. Bio ATP 3 x 1
7. Mobilisasi miring
kanan-kiri, duduk
ROM pasif
8. Perawatan
Tracheotomy
9. Fisioterapi