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  • CLINICAL PATHWAYS FOR SEVERE ASPHYXIA

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    suraya
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    This document contains a clinical pathway for a patient diagnosed with severe asphyxia over 14 days of treatment. It details the patient's diagnosis, treatment plan, assessments, lab results, medications and nutrition administered each day. Plus and minus signs are used to track whether interventions/tests were performed or findings on a given day. The goal of the pathway is to document the patient's care and recovery over their hospital stay.

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    Clinical Phatway ASFIKSIA

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    This document contains a clinical pathway for a patient diagnosed with severe asphyxia over 14 days of treatment. It details the patient's diagnosis, treatment plan, assessments, lab results, medications and nutrition administered each day. Plus and minus signs are used to track whether interventions/tests were performed or findings on a given day. The goal of the pathway is to document the patient's care and recovery over their hospital stay.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    28 views3 pages

    CLINICAL PATHWAYS FOR SEVERE ASPHYXIA

    Uploaded by

    suraya
    This document contains a clinical pathway for a patient diagnosed with severe asphyxia over 14 days of treatment. It details the patient's diagnosis, treatment plan, assessments, lab results, medications and nutrition administered each day. Plus and minus signs are used to track whether interventions/tests were performed or findings on a given day. The goal of the pathway is to document the patient's care and recovery over their hospital stay.

    Copyright:

    © All Rights Reserved
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    of 3

    CLINICAL PATHWAYS

    ASFIKSIA BERAT
    RSKIA ANNISA
    BANJARMASIN

    Nama Pasien : Umur Berat Badan Panjang Badan Nomor Rekam Medis
    kg cm
    Diagnosa Awal : ASFIKSIA BERAT Kode ICD 10 : P21.0 Rencana rawat :14 hari
    R.Rawat Tgl/Ja Tgl/Ja Lama Rawat kelas : Tarisf/hr (Rp) Biaya (Rp)
    masuk : m keluar : m hari

    Aktivitas Pelayanan
    Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil Hasil
    Rawat Rawat Rawat Rawat Rawat Rawat Rawat Rawat Rawat Rawat 10 Rawat 11 Rawat 12 Rawat 13 Rawat 14
    1 2 3 4 5 6 7 8 9 Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit
    Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit Hari Sakit
    Diagnosa ASFIKSIA BERAT
    Penyakit Utama ASFIKSIA BERAT
    Penyakit Penyerta + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Komplikasi + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Asessmen Klinis :
    Pemeriksaan Dokter + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Konsultasi + - + - + - + - + - + - + - + - + - + - + - + - + - + -

    Pemeriksaan Penunjang
    Hemoglobin + - + - + - + - + -
    Leukosit + - + - + - + - + -
    Hematrokit + - + - + - + - + -
    Trombosit + - + - + - + - + -
    LED + - + - + - + - + -
    Diffcount + - + - + - + - + -
    GDS + - + - + - + - + -
    CRP + - + - + - + - + -
    IT Ratio + - + - + - + - + -
    RO Thoraks + -
    Tindakan :
    Oksigen Nasal prongs + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    CPAP + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Pasang IVFD + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Aff Infus
    Rawat dalam inkubator + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Obat obatan :
    Dextroses 10% + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    NaCl 0.9% + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    KCl 1 meq/50 cc cairan infus + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Ca Gluc 1cc/50 cc cairan infus + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Lipid 20% + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Aminofusin Paed + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Ampicilin Sulbactam 100 mg/KgBB/hari 2 kali/hari + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Amikasin 15 mg/KgBB/hari 2 kali/hari + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Cefoperazon 100 mg/KgBB/hari 2 kali/hari + - + - + - + - + - + - + - + - + - + - + -
    Gentamicin 5 mg/KgBB/hari 2 kali/hari + - + - + - + - + - + - + - + - + - + - + -
    Meropenem 40 mg/KgBB/kali 3 kali/hari + - + - + - + - + - + - + - + -
    Ranitidin 1 mg/KgBB/kali 3 kali/hari + - + - + - + - + - + - + - + - + - + - + - + - + - + -

    Nutrisi
    Melalui OGT + - + - + - + - + - + - + - + - + - + - + -
    Peroral + - + - + - + - + - + - + - + - + - + - + -
    Hasil (Outcome) :
    Kesadaran + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Febris ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ --
    ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ --
    Sesak napas
    Kejang ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ -- ++ --
    Perdarahan + - + - + - + - + - + - + - + - + - + - + - + - + - + -
    Keadaan umum + - + - + - + - + - + - + - + - + - + - + - + - + - + -

    Pendkan/RencPemulangan : Penj. perjalanan penyakit


    Nasehat berobat teratur
    Diagnosa Akhir : Kode ICD 10 enis Tindakan : Jumlah Biaya
    J
    Utama Visite & konsultasi
    Penyerta IVFD dan injeksi

    Komplikasi
    Perawat :

    Dokter
    Penanggung Jawab
    Y4C5
    Pasien (DPJP)
    Verifikator :

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