2B.

Ny Entin /P/55kg/ 60 kg/ 0002059714/ HP 1

Objectives Assessment Planning

CNS : E4M6vet Post Craniotomi Tumor Removal ai SOL supratentorial at left parietal due to convexity meningioma P
F : test feeding
A : Fentanyl 25 mcg/jam, Paracetamol
1gr/6jam
S:-
CVS : 21/7/2022 T : (-)
TD: 123/94 mmHg Hb 9,6 Ht 27,5 L 22.430 T 123.000 GDS 121 na 140 K 3,3 Cl 104 Ca 4,93 H : Head up 30⁰
N: 69-72 x/menit, regular pH 7,487 pCO2 28,4 pO2 158,4 HCO3 21,7 BE -1,0 sao2 95,4
U : Omeprazole 40 mg/12 jam IV
20/7/22 (Post operasi G:-
Respirasi )Hb 9,0 Ht 25,4 L 28.210 Tr 104.000 PT 17,6 INR 1,25 aPTT 34,50 Alb 2,30 gds 216Ur 15,2 Cr 0,30 Na 139 K 3,1 Cl Terapi lainnya:
R: 12 x/menit dengan Ventilator mode spont 105 Ca 4,4 laktat 1,7 pH 7,3470 pCO2 28,1 pO2 223,9 HCO3 20,7 BE -1,8 SaO2 98,7 - Ceftriaxone 1gr/12 jam (H1)
ps 5 peep 5 fio2 50% tercapai vt 382-405 mve - Vitamin K 10mg/8jam
4,5 L Spo2 99%
- asam tranexamat 500 mg/8jam
- fenitoin 100 mg/8jam
GIT
BU(+)

GUT
UO : 25-25-40cc/jam
Balans : +621 cc/13 jam
20/7/2022