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ACUTE PAIN SERVICE IN
GENERAL PRACTICE
Departemen Anestesiologi dan Terapi Intensif
Fakultas Kedokteran USU / RSUP. Haji Adam Malik Medan
2013
Juan C.R.N. Marbun 080100062
Sweet Caroline Marpaung 080100105
Revinanda V. Pangaribuan 080100159Pembimbing : dr. Qodri F. Tanjung, Sp.An, KAKV
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PENDAHULUAN
Tatalaksana nyeri MUTLAK dikuasaisemua dokter
Salah satualasan utama
datang berobat/mencari
pertolonganmedis
UU KesehatanNo. 36 tahun
2009
Setiap orangberhak bebasdari nyeri
Nyeri adalahvital sign yang
kelima (Thefifth vital sign)
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DEFINISI NYERI
International Association for the Study of
Pain Pengalaman sensoris danemosional yang tidak menyenangkan
yang disertai oleh kerusakan jaringan
secara potensial dan aktual
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KLASIFIKASI NYERI
NYERI
NYERI
KRONIK
NYERI
AKUT
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NYERI AKUT
• Nyeri akut didefinisikan sebagai nyeri yang
disebabkan stimulasi berbahaya yang
berhubungan dengan kerusakan jaringan,
proses penyakit, dan fungsi abnormal ototatau organ viseral.
• Nyeri akut:
– Nyeri Somatik
– Nyeri Viseral
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Mekanisme Nyeri
Spinothalamictract
Peripheral
nerve
Dorsal Horn
Dorsal root ganglion
Pain
Ascending
input
Descending
modulation
Peripheral
nociceptors
Trauma
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
PERCEPTION
MODULATION
TRANSMISSION
TRANSDUCTION
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Zat Sumber Nyeri yang
Timbul
Efek pada Aferen
Primer
Kalium Sel-sel rusak ++ Mengaktifkan
Serotonin Trombosit ++ Mengaktifkan
Bradikinin Kininogen plasma +++ Mengaktifkan
Histamin Sel-sel mast + Mengaktifkan
Prostaglandin Asam arakidonat dan sel
rusak
± Sensitisasi
Leukotrien Asam arakidonat dan sel
rusak
± Sensitisasi
Substansi P Aferen primer ± Sensitisasi
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Respon sistemik terhadap nyeri akut
• Respon neuroendokrin peningkatan hormonkatabolik (katekolamin, kortisol, glukagon, renin,aldosteron, angiotensin, hormon antidiuretik)
dan penurunan hormon anabolik (insulin,testosteron).
• Manifestasi nyeri dapat berupa hipertensi,takikardi, hiperventilasi (kebutuhan O2 dan
produksi CO2 meningkat), tonus sfingter salurancerna dan saluran kemih meningkat (ileus, retensiurin).
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Penilaian/Asessment Nyeri Akut
• Anamnesis
– Riwayat penyakit sekarang
– Riwayat pembedahan terdahulu
– Riwayat psikososial
– Riwayat pekerjaan
– Obat-obatan dan alergi
– Riwayat keluarga
– Asesmen sistem organ yang komprehensif
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Penilaian/Assesment Nyeri Akut
• Pemeriksaan Fisik
– Pemeriksaan umum
– Status mental
– Pemeriksaan sendi
– Pemeriksaan motorik
– Pemeriksaan sensorik
– Pemeriksaan neurologis lainnya
– Pemeriksaan khusus
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Penilaian/Assesment Nyeri Akut
• Pemeriksaan Penunjang
– EMG
– Sensorik kuantitatif
– Pencitraan (radiologi)
– Pemeriksaan psikologi
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Pengukuran Nyeri
• SUBJEKTIF
– Numeric Rating Pain Scale (Anak > 7 tahun – dewasa)
• OBJEKTIF
– Wong Baker Pain Rating Scale ( Anak > 3 tahun dan
dewasa),
– Flacc Behavioral Pain Scale ( Bayi 2 bulan – 7 tahun ),
– Cries Pain Score ( neonatus dan bayi 0-6 bulan), – Comfort Pain Scale (bayi, anak, dewasa dan tidak
sadar)
– Verbal Analog Scale
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Numeric Rating Pain Scale
Numeric Rating Scale:
• 0=tidak merasakan nyeri; dan 10=nyeri yang berat
• Nyeri ringan skala 1-3
• Nyeri sedang skala 4-7
• Nyeri berat 8-10
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Wong Baker Pain Rating Scale
Wong-Baker Face Scale:0=tidak merasakan nyeri; dan 10=nyeri yang sudah berat.Nyeri ringan 1-3Nyeri sedang 4-6Nyeri berat 7-10
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VISUAL ANALOG SCALE
Visual Analog Scale:Nyeri ringan 0-4
Nyeri sedang 4-7
Nyeri berat 7-10
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Penatalaksanaan Farmakologi
WHO ANALGESIC LADDER
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NSAID ±adjuvant analgesic
± weak opioid(codeine)
paracetamol
or NSAID ±adjuvant analgesic
Strong opioid
± NSAID ±adjuvant analgesic
WHO ANALGESIC LADDERChoosing pain killer and its combinations
0 1 2 3 4 5 6 7 8 9 10
Pain tolerancePain threshold
mild moderate severe
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OPIOID
• Opioid adalah semua zat baik sintetik atau
natural yang dapat berikatan dengan reseptor
morfin
• Reseptor morfin terdapat di otak tengah yaitu
di sistem limbik, talamus, hipotalamus, korpus
striatum, sistem aktivasi retikular dan di korda
spinalis yaitu di substansia gelatinosa dandijumpai pula di pleksus saraf usus.
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RESEPTOR OPIOID
• Reseptor μ (mu): terdiri dari reseptor μ-1 yangbertanggung jawab untuk analgesia supraspinal, sedasidan reseptor μ-2 untuk analgesia spinal, depresi napas,eforia, ketergantungan fisik, kekakuan otot.
•Reseptor δ (delta): bertanggung jawab untuk analgesiaspinal dan bersifat epileptogen
• Reseptor κ (kappa): terdiri dari reseptor κ-1 yangterlibat dalam analgesia spinal, κ-2 yang tidak diketahuifungsinya, dan κ-3 yang bertanggung jawab dalam
analgesia supraspinal.• Reseptor σ (sigma): disforia, halusinasi, stimulasi
jantung.
• Reseptor ε (epsilon): respon hormonal.
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KLASIFIKASI OPIOID
• Agonis: bersifat mengaktifkan reseptor.Contoh: morfin, papaveretum, petidin(meperidin, demerol), fentanil, alfentanil,
sufentanil, remifentanil, kodein, alfaprodin.• Antagonis: tidak mengaktifkan reseptor dan
pada saat bersamaan mencegah agonis
merangsang reseptor. Contoh: nalokson,naltrekson.
• Agonis-antagonis: Pentasosin, nalbufin,butarfanol, buprenorfin
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ANTI INFLAMASI NON STEROID
• PARASETAMOL
Antipiretik pada hypothalamus (termoregulasi
panas central)2 Mekanisme : menghambat
produksi prostaglandin di otak dimana saatdemam, konsentrasi prostaglandin tinggi di CSF
Analgetik bekerja di otak dan medula spinalis
dengan cara berkonjugasi dengan asamarakhidonat menghasilkan aktivator analgetik
endogen (N-arachidonoylphenolamine (AM404))
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ANTI INFLAMASI NON STEROID
• PARASETAMOL – Onset analgesia : 11 menit
– Waktu paruh : 1 – 4 jam
–
Dosis• Antipiretik : 10 mg/kgBB/kali beri
• Analgetik : 15-20 mg/kgBB/kali beri
– Interval : 4-6 jam
–
Dosis maksimum : 4.000 mg/hari, atau 75 mg/kgBB/haripada anak <12th
– Metabolisme : Hati
– Ekskresi : Ginjal
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ANTI INFLAMASI NON STEROID
PARASETAMOL PADA DOSISREKOMENDASI
1. Tidak mengiritasi lambung
2. Tidak mempengaruhi
koagulasi darah3. Tidak mempengaruhi fungsi
ginjal
4. Aman pada wanita hamil
5. Tidak berhubungan dengansindroma Reye pada anak
DOSIS > 20.000 mg/hr
1. Hepatotoksik
2. Gangguan gastrointestinal
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ANTI INFLAMASI NON STEROID
• KETOROLAC
– Dosis : 0,5-0,75 mg/kg/IV
– Mekanisme kerja : menghambat sintesa
prostaglandin (COX) terutama COX-1. Efekinflamasinya kurang dibandingkan efek analgesinya
– Onset analgesia : 10 menit
– Efek puncak : 2 – 3 jam
– Efek samping dari ketorolac meliputi hipersensitivitas
pada saluran napas, agregrasi trombosit, erosi mukosa
gastrointestinal, dan gangguan fungsi ginjal
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ANTI INFLAMASI NON STEROID
• NATRIUM DIKLOFENAK
– Absorpsi obat melalui saluran cerna berlangsungcepat dan lengkap.
– Waktu paruh singkat (1-3 jam), diakumulasi di cairansinovial sehingga efek terapi di sendi jauh lebihpanjang
– Efek samping : mual, gastritis, eritema kulit, dan sakitkepala.
– Pemakaian selama kehamilan tidak dianjurkan
– Dosis orang dewasa : 100-150 mg sehari terbagi duaatau tiga dosis
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PENATALAKSANAAN NON
FARMAKOLOGI
• Terapi perifer
– Terapi panas-dingin
– Akupuntur
– Olahraga
– Pijat
– TENS (Transcutaneous Electrical Nerve
Stimulation)
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PENATALAKSANAAN NON
FARMAKOLOGI
• Terapi kognitif
– Hipnosis
– Meditasi
– Yoga
• Terapi lain
– Aromaterapi
– Terapi musik
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Identitas Pasien
Nama : PWJenis Kelamin : Perempuan
Usia : 45 tahun
Suku Bangsa : Indonesia
Agama : Islam
Alamat : Jl. Karya Tani gg
Pinang No.40 Medan Johor.
Status : Sudah menikahPekerjaan : Ibu Rumah tangga
Tanggal Masuk : 11 Mei 2013
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• Anamnesis:Luka bakar pada seluruh
tubuh.
• Mode of injury: Akibat ledakan
kompor masak pada ruangan terbuka.
• Injury sustain: Luka bakar 36% grade
IIa-IIb
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Primary
Survey
Gejala Kesimpulan Tindakan Evaluasi
A Look Listen Feel (+)Snoring: (-) Gargling:
(-) Crowing: (-)
Airway: clear.Terjadi luka bakar
pada muka.
Curiga akan
terjadi edema
laring.
Intubasi Look Listen Feel(+), Airway tetap
clear.
B RR: 36 bpm
SP/ST: vesikuler/-
SpO2: 90%
Hipoksemia O2 sungkup non-
rebreathing 10 l/i
SP/ST:
vesikuler/-
SpO2 : 98%
RR 24 bpm
C Akral: H/M/K
Pulse: (+), reg, t/v
kuat/cukup, frek 127
bpm
TD: 175/96 mmHg
Hemodinamik tidak
stabil. Tekanan
darah meninggi dan
takikardia.
- IV line 18 G dan
pasang 2 jalur iv line
- IVFD RL 5000 cc/
8 jam pertama
5000 cc/ 16 jam
kedua
Akral: H/M/K
Pulse: (+), reg,
t/v,kuat/cukup,
Frek 88 bpm
TD 130/80
mmHg
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D Sens: GCS 15,
pupil isokor,
3mm/3mm,
RC: +/+
Kesadaran
baik.
- Head up 30º Sens : GCS
15, pupil
isokor,
3mm/3mm,RC:+/+
E Luka bakar.
Pada muka
sebelah kanan,lengan kanan
bagian depan,
dada kanan
depan dan belakang dan
tungkai bawah
kanan bagian
depan.
Luka bakar
36 % grade
IIa dan IIb.
- Rencana
debridemen
t
-
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• Posisi head up 300
• Intubasi
•
IV line terpasang 18 G, pastikan lancar,dengan resusitasi cairan RL
• Kebutuhan cairan:
4 x 70 x 36% =10080cc/24 jam, 5040 cc (8 jam pertama) dan 5040 cc (16 jam kedua)
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Airway: Clear, terintubasi. RR: 24x/i, Sp: Vesikular,
ST: -, SpO2: 98%, Gargling/Snoring/Crowing : -/-/--/-
/-, Riwayat sesak/ asma/batuk/alergi (-/-/-/-), Skor
Mallampatti: 1, JMH > 6 cm, Gerak leher : bebas.
B2 Akral: H/M/K, Pulse: 88x/I, regular, kuat, TD:
130/80 mmHg
B3 Sens: Compos Mentis, Pupil isokor, Ø:
3mm/3mm,
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B6
Abdomen: soepel, peristaltik (+),
mual (-), muntah (-) , MMT jam 1300 wib
,
Edema (-) , fraktur (-)
B4UOP: +, terpasang kateter, vol
50cc/jam, warna kuning jernih
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• Inj . ATS 3000 IU ( IM)
• Kateter terpasang dengan UOP 50cc/jam
• Monitoring hemodinamika dan saturasi oksigen
• Untuk mencegah infeksi diberikan antibiotik
yang adekuat : Inj Ceftriaxone 1 g/ IV• Untuk mencegah nyeri diberikan analgetik:
Inj Ketorolac 30 mg/ 6jam/ IV
•
Ambil sampel darah dan cek laboratorium
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Jenis Pemeriksaan Hasil
Hb/Ht/leukosit/Plt 16.20 gr% / 47.50% / 23.71 x 103/mm3 /320.000/mm3
pH/PCO2/PO2/HCO3/tot
CO2/BE/SpO2
7,426/32,7/121,9/21,0/22,1/-2.3/98,7
Ur/Cr 23,10 mg/dl / 1,07 mg/dl
KGD Ad Random 151 mg/dl
Na/K/Cl 137 mEq/L /3,8 mEq/L/ 110 mEq/L
pH/pCO2/pO2/HCO3/Total
CO2/ BE/ Sat O2
7,382/33,8/ 185,0/19,6/20,6/-4,6/99,6
Pemeriksaan Lab
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Foto Toraks dalambatas normal.
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• Anamnesis: Autoanamnese
• Keluhan utama: Luka bakar pada seluruh
tubuh. Hal ini dialami pasien 2 jam yang lalu
akibat ledakan kompor masak pada ruangan
terbuka. Pingsan (-).
• Riwayat Penyakit Terdahulu: Tidak ada
• Riwayat Penyakit Dalam Keluarga : Tidak
ada
TELAAH
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Diagnosis: Luka bakar 36%,
grade IIa- IIb
Tindakan Debridement, PS ASA:
2E, Anestesi dengan GA-ETT,Posisi Supine
Tindakan Anestesi Pra-Debridement
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Tindakan Anestesi Pra-Debridement • Oksigenasi 8 lpm
• Premedikasi :
•
Midazolam 3,5 mg IV• Fentanyl 100 mcg IV
• Medikasi :
• Propofol 100 mg IV
• Rocuronium 40 mg IV• Teknik anestesi menggunakan GA-ETT dengan PS ASA II
untuk derajat luka bakar 35% supine premedikasioksigenasi induksi propofol relaksasi denganrocuronium insersi ETT 6,5 cuff (+) ,suara pernafasankanan=kiri fiksasi
• Oksigen : N2O = 2:2 l/menit, isoflurane 0,4-0,6%
• Injeksi ketamin 30 mg IV saat awal debridement.
S Post- OP hari ke 11 (15/5/2013)
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S ( / / )
O B1: Airway: Clear, terintubasi dengan T-piece 5l/I, RR:16x/i, SP: Vesikuler, ST:
(-) RR:20x/I SpO2:100%
B2: Akral H/M/K, TD:160/100mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernihB5:Abdomen soepel, peristaltic (+) N
B6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB
P Diet: SV 1500kkal + 100gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD RL 20gtt/i
IVFD Albumin 1 fls/ hari
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Morfin 20mg+ Midazolam 30mg
3cc/jam (dalam 50cc NaCl 0,9%)Inj Perdipin 12cc /jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj Farmadol kalau perlua
Tab Nature E 1x1
S Post- OP hari ke 12 (16/5/2013)
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( / / )
O B1: Airway: Clear, terintubasi dengan T-piece 5l/I, RR:16x/i, SP: Vesikuler, ST: (-)
RR:20x/i
B2: Akral H/M/K, TD:160/100mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernihB5:Abdomen soepel, peristaltic (+) N
B6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB
P Diet: SV 1500kkal + 100gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/iIVFD RL 20gtt/i
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Morfin 20mg+ Midazolam 30mg 3cc/jam (dalam 50cc NaCl 0,9%)
Inj Perdipin 12cc /jam
Inj Vitamin C 1gr/24 jamInj Methylpredisolon 62,5 mg/ 8 jam
Inj Farmadol kalau perlu
Tab Bisoprolol 1x2,5 mg
Tab Nature E 1x1
S Post- OP hari ke 13 (17/5/2013)
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S Post- OP hari ke 13 (17/5/2013)
O B1: Airway: Clear, terintubasi dengan T-piece 5l/I, RR:16x/i, SP: Vesikuler, ST: (-) RR:20x/i
B2: Akral H/M/K, TD:160/100mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB
P Diet: SV 1500kkal + 100gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
Fisioterapi
IVFD Plasmanat 10 gtt/iIVFD RL 20gtt/I 5/5 D5 20gtt/i
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Perdipin 12cc /jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Tab Amlodipin 1x10mgTab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5
Tab Nature E 1x1
Cek KGD, Electrolit, AGDA, Darah Lengkap,
S Post- OP hari ke 14 (18/5/2013)
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S Post OP hari ke 14 (18/5/2013)
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:20x/i
B2: Akral H/M/K, TD:140/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2000kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD RL 20gtt
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Perdipin 20mg + NaCl 0,9% 50 cc, 10gtt/i
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jamTab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Cek KGD, Electrolit, AGDA, Darah Lengkap, Tes Fungsi Ginjal, PCT
S Post- OP hari ke 15 (19/5/2013)
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S Post- OP hari ke 15 (19/5/2013)
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:20x/i
B2: Akral H/M/K, TD:140/100mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2000kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD RL 20gtt
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Perdipin 20mg + NaCl 0,9% 50 cc, 10gtt/i
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
S Post- OP hari ke 16 (20/5/2013)
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( / / )
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:140/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 100gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/iInj Meropenem 1gr/8jam
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj morphine 10g + Midazolam 15mg 5cc/jamTab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
S Post- OP hari ke 17 (21/5/2013)
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S Post- OP hari ke 17 (21/5/2013)
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:180/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 800gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/i
Inj Meropenem 1gr/8jam
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj morphine 10g + Midazolam 15mg 5cc/jam
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Rencana debridement 22/5/2013
S Post- OP hari ke 18 (22/5/2013)
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S Post OP hari ke 18 (22/5/2013)
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:130/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) N
B6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/i
Inj Meropenem 1gr/8jamInj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Ronem igr/ 8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj Farmadol kalau perlu
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Cek Darah Lengkap, HST, KGD ad random, RFT, elektrolit, AGDA
S Post- OP hari ke 19 (23/5/2013)
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O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:130/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/iInj Meropenem 1gr/8jam
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Ronem igr/ 8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jamInj Farmadol kalau perlu
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Cek Darah Lengkap, HST, KGD ad random, RFT, elektrolit, AGDA
S Post- OP hari ke 20 (24/5/2013)
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S Post OP hari ke 20 (24/5/2013)
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:130/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/i
Inj Meropenem 1gr/8jam
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj Farmadol kalau perlu
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Cek Darah Lengkap, HST, KGD ad random, RFT, elektrolit, AGDA
S Post- OP hari ke 21(25/5/2013)
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( / / )
O B1: Airway: Clear, spontaneous breathing, SP: Vesikuler, ST: (-) RR:22x/i
B2: Akral H/M/K, TD:140/90mmHg, HR: 88x/i,regular, T/V
B3: Sens: CM, pupil isokor, Ø: 3mm/3mm, RC: +/+
B4: UOP (+), Vol:40cc/jam, warna: kuning jernih
B5:Abdomen soepel, peristaltic (+) NB6: Fraktur (-), Edema (+) leher dan bahu
A Luka bakar 36% grade IIA-IIB + post debridement
P Diet: SV 2400kkal + 80gr protein + 10 butir telur putih/ hari
Bed Rest head elevated 30º
IVFD Plasmanat 10 gtt/i
IVFD Ringer Fudin 20gtt/iInj Meropenem 1gr/8jam
Inj Ceftriaxone 2gr/ 12 jam
Inj Ranitidine 80 mg/8 jam
Inj Vitamin C 1gr/24 jam
Inj Methylpredisolon 62,5 mg/ 8 jam
Inj Farmadol kalau perlu
Tab Amlodipin 1x10mg
Tab Captopril 3x25 mg
Tab Bisoprolol 1 x 2,5mg
Tab Nature E 1x1
Cek Darah Lengkap, HST, KGD ad random, RFT, elektrolit, AGDA
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TERIMA KASIH