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  • Lembar Monitoring Icu Ke 1

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    This document summarizes the monitoring of a patient's hemodynamics over 4 days of treatment. It records the patient's vital signs, intake and output, medications and treatments administered, and lab results. The patient received IV fluids, medications to treat respiratory distress, and nutrition via NGT. Their vital signs and oxygen levels were closely monitored.

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    This document summarizes the monitoring of a patient's hemodynamics over 4 days of treatment. It records the patient's vital signs, intake and output, medications and treatments administered, and lab results. The patient received IV fluids, medications to treat respiratory distress, and nutrition via NGT. Their vital signs and oxygen levels were closely monitored.

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    © All Rights Reserved
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    22 views5 pages

    Lembar Monitoring Icu Ke 1

    Uploaded by

    elfirasuci
    This document summarizes the monitoring of a patient's hemodynamics over 4 days of treatment. It records the patient's vital signs, intake and output, medications and treatments administered, and lab results. The patient received IV fluids, medications to treat respiratory distress, and nutrition via NGT. Their vital signs and oxygen levels were closely monitored.

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    © All Rights Reserved
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    of 5

    LEMBAR MONITORING HEMODINAMIK

    TANGGAL: 02-05-2019 HARI PERAWATAN: 4 BB: 65 Kg


    MONITORING

    JAM DX TINDAKAN/KEGIATAN intake Output


    jam LOC HR TD MAP RR T SPO2 EKG CVP Blnc
    O/E P Urin IWL
    07.00 1 - Memonitor tanda-tanda 07.00 CM 88 119/70 86 20 36,0 100% SR
    vital 08.00 CM 89 119/70 86 25 36,0 100% SR
    07.40 - Melakukkan personal 09.00 CM 85 120/70 86 26 36,4 99% SR
    Hygiene 10.00 CM 87 109/62 78 27 36,2 99% SR
    08.00 - Memberikan obat 11.00 CM 92 100% SR
    12.00 CM 84 98% SR
    13.00 CM 90 100% SR
    14.00 CM 87 100% SR
    Diet: Terapi/Cairan & obat titrasi Ventilator/terapi oksigen
    - RL 39ml/jam Nasal kanul 3lpm
    LAB:
    - Hb : 9,3 g/dL - CI : 101,9
    EVALUASI
    - Ht : L 26,1 g/dL
    - Monitor tanda-tanda vital/jam
    - Leukosit : 25,040/uL
    - Monitor respirasi dan status oksigen pasien
    - Trombosit 125.000/uL - Batasi gerakan pada kepala, leher dan punggung
    - albumin : 2,80
    - Na : 136,3
    - k : 5,63
    LEMBAR MONITORING HEMODINAMIK

    TANGGAL: 26-02-2019 HARI PERAWATAN: 4 BB/TB: 60 Kg/175


    MONITORING

    JAM DX TINDAKAN/KEGIATAN intake Output


    jam LOC HR TD MAP RR T SPO2 EKG CVP Blnc
    O/E P Urin IWL
    14.00 2 - Memonitor tanda-tanda 14.05 74 130/80 93 32 37,6 98 SR - 74 600
    vital 15.00 83 132/82 92 30 37,1 97 SR - 83
    15.00 - Melakukkan suction 16.01 80 155/85 102 29 37.5 92 SR - 80
    17.05 - Memberikan obat Retaphyl 17.00 79 159/85 111 30 36,8 93 SR - 79
    Theophlyline 300 mg, 18.00 74 162/90 109 33 36,6 88 SR - 74
    ambroxol 3x1 mg, 19.00 85 149/85 112 28 36,1 93 SR - 85
    salbutamol 3x2 mg 20.00 84 137/82 104 31 36,4 92 SR - 84
    17.45 - Memberikan nutrisi 21.00 82 149/85 105 30 37.2 98 SR - 82
    melalui selang NGT Diet: Terapi/Cairan & obat titrasi Ventilator/terapi oksigen
    Susu 150 cc melalui selang NGT - NaCl 0,9 % 500 ml/24 jam NRM 12 Liter
    - Manitol 200 ml/jam
    - Futrosit 500 cc/24 jam
    LAB: - Asering 83 ml/jam
    Hb : 12. 8g/dL
    EVALUASI
    Ht : 39.1 g/dL
    - Monitor tanda-tanda vital
    Eritrosit : 4.21 /uL
    - Monitor respirasi dan status oksigen pasien
    Kreatinin darah 0,95 mg/dL
    - Batasi gerakan pada kepala, leher dan punggung
    Ureum : 47 mg/dL
    Natrium : 149.3 mEq
    LEMBAR MONITORING HEMODINAMIK

    TANGGAL: 27-02-2019 HARI PERAWATAN: 5 BB/TB: 60 Kg/175


    MONITORING

    JAM DX TINDAKAN/KEGIATAN intake Output


    jam LOC HR TD MAP RR T SPO2 EKG CVP Blnc
    O/E P Urin IWL
    21.00 3 - Memonitor tanda-tanda 21.00 70 137/80 102 28 36,8 86 SR - 70 500
    vital 21.15 74 132/82 109 30 36,6 93 SR - 74
    21.10 - Melakukkan suction 22.00 80 137/85 116 32 37.1 92 SR - 80 600
    21.45 - Memberikan obat Retaphyl 23.00 71 160/90 115 33 37.5 93 SR - 71
    Theophlyline 300 mg, 00.05 87 161/93 112 28 36,8 89 SR - 87
    ambroxol 3x1 mg, 01.00 90 157/90 118 26 36,6 92 SR - 90
    salbutamol 3x2 mg 03.00 88 150/85 110 28 36,5 98 SR - 88
    22.00 - Memberikan nutrisi 06.00 80 137/85 105 30 36.2 100 SR - 80
    melalui selang NGT Diet: Terapi/Cairan & obat titrasi Ventilator/terapi oksigen
    06.00 - Melakukkan personal Susu 150 cc melalui selang NGT - NaCl 0,9 % 500 ml/24 jam NRM 10 Liter
    Hygiene - Manitol 200 ml/jam
    - Futrosit 500 cc/24 jam
    LAB: - Asering 83 ml/jam
    Hb : 12.8 g/dL
    EVALUASI
    Ht : 40.0 g/dL
    - Monitor tanda-tanda vital
    Leukosit : 13.850 g/dL
    - Monitor respirasi dan status oksigen pasien
    Natrium : 147.1 mEq
    - Batasi gerakan pada kepala, leher dan punggung
    Kalium : 4, 11

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