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Follow Up DCFC
Follow Up DCFC
18 November 2015
Hari perawatan ke-0
Subjektif
Objektif
Sesak sudah berkurang, B1 : airway clear, breathing
batuk berdahak, nyeri spontan
rr : 17x/m, SpO2: 100%
kepala berputar
dengan NRM 10 lpm
Rh --+/--+, wh -/B2 : TD : 116/69
N : 64x/m, akral HKM
S1S2 tunggal m(-) g(-)
B3 : GCS 456, PBI
3mm/3mm, RC +/+
Assesment
DCFC IV + Edema
paru e.c Cardiogenik
+ Susp Pneumonia
Planning
Dr. Huluwiyah Sp.An:
- Head up 30o
- O2 masker NRM 10 lpm
- Fisioterapi nafas
- Nebul pz + ventolin +
bisolvon 6x/hari
- Suction sesuai indikasi
- Oral dan personal hygiene
2 kali/24 jam
- Oral dan personal hygiene
2 kali/24 jam
- Infus Asering 1000 cc/24
jam
- Sementara puasa
- Injeksi Ranitidine 2x 50
mg
- Injeksi Bisolvon 3x1
- Injeksi Ceftriaxon 2 x 1 g
- Pump furosemide
3mg/jam
- Drip neurobion 1amp
dalam 100ccpz/24jam
Dr. Bayu Sp.PD:
- Tx lanjut
13,2/4.69/10.700/188.000
OT/PT/Alb: 25,3/15,5/3,6
BUN/SK/AU:10,1/1,3/4,2
19 November 2015
Na/K/Cl:135,4/3,61/107,58
B1 : airway clear, breathing
DCFC IV + Edema
putih (+)
spontan
rr : 24x/m, SpO2: 100%
dengan NRM 10 lpm
Rh -/-, wh -/B2 : TD : 138/84
N : 93x/m, akral HKM
S1S2 tunggal m(-) g(-)
B3 : GCS 456, PBI
3mm/3mm, RC +/+
B4 : Supel, BU+N, nyeri
tekan (-), H/L tak teraba
B5 : produksi urin 50cc/jam
B6 : edema -/Term 36,7
Lab :
GDA : 134 mg/dL
Hb/Eri/Leu/Tro:
Head up 30o
O2 masker 8 lpm
Fisioterapi nafas
Nebul pz + ventolin +
bisolvon 6x/hari
Suction sesuai indikasi
Oral dan personal hygiene
2 kali/24 jam
Oral dan personal hygiene
2 kali/24 jam
Infus Asering 1000 cc/24
jam
Diet bubur halus 1800kal
Minum maksimal
300cc/hari
Injeksi Ranitidine 2x 50
mg
Injeksi Bisolvon 3x1
Injeksi Ceftriaxon 2 x 1 g
Pump furosemide
4mg/jam
Drip neurobion 1amp
dalam 100ccpz/24jam
12,8/4.66/13.000/200.000
Na/K/Cl:133,23/3,54/102,7
6
30
20 November 2015
Hari perawatan ke-2
DCFC IV + Edema
paru e.c Cardiogenik
+ Susp Pneumonia
12.8/4.47/10.100/197.000
Na/K/Cl:131,77/3,57/106,6
0
31
21 November 2015
Hari perawatan ke-3
DCFC IV + Edema
paru e.c Cardiogenik
+ Susp Pneumonia
12,9/4.64/10.800/185.000
Na/K/Cl:134,1/3,57/101,3
32
22 November 2015
Hari perawatan ke-4
DCFC IV + Edema
paru e.c Cardiogenik
+ Susp Pneumonia
12,9/4.64/10.800/185.000
Na/K/Cl:134,1/3,57/101,3
33
23 November 2015
Hari perawatan ke-5
DCFC IV + Edema
paru e.c Cardiogenik
+ Susp Pneumonia
12,8/4.64/10.900/189.000
34