FU BU 1 Okt 2015
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FOLLOW UP PASIEN DI BURN UNIT Identitas : Ngatmini, P, 45 thn, 1736977, 60kg Diagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+37 post release kontraktur, STSG, FTSG H+6 Tanggal : 1 Oktober 2015 HariKe- : 62 OBJEKTIF Tgl 1 Oktober 2015 (05.00) S : Demam (-), kejang (-), nyeri (+) berkurang, VAS = 2-3 O : KU sedang, CM Vital Sign : BP : 120/70 mmHg HR : 84 x/mnt RR : 18 x/mnt T : 36,9°C MAP : 87 Assessment - Vulnus Granulosum 4% TBSA ec Combustio - Post debridement + STSG (6/8/2015) - Post release kontraktur + STSG +FTSG (25/9/2015) IWL = (25+4%)x1.58x24jam = 47.4x24 = 1100 cc Kebutuhan Cairan = (1500xTBSA)+IWL =(1500x1,58) + 1138 cc = 3508 cc/24 jam Kebutuhan Kalori =(25xBB)+(40x%LB) =(25x60)+(40x4) =1660 kkal/24jam PERKEMBANGAN 28.9.2015 Hb 10,1 AE 3.46 AL 8,97 AT 344 HCT 29,6 Alb 3,22 GDS 81 Na 136 K 3.2 Cl 103 26.9.2015 Hb 10,3 AE 3.49 AL 8,4 AT 385 HCT 29,9 Alb 3,03 GDS 231 Na 135 K 3.6 Cl 103 24.9.2015 Hb 11.3 AE 3.87 AL 7.31 AT 406 HCT 33 PPT 13.8 APTT 25.4 INR 1.0 Alb 3,54 BUN 11.6 Crea 0.49 GDS 171 Na 137 K 3.9 Cl 104 MASALAH Penyembuhan luka Balance Cairan : CM : 2950 cc/24 jam CK : 2350 cc/24 jam IWL : 1100 cc/24 jam BC : -500 cc/24 jam BC kumulatif : -15 cc Diuresis: 1,63 cc/ kgBB/ jam UO : 350 cc/ 3 jam terakhir Plan Awasi KU/VS/BC Inj. Ceftriaxon 1 g/ 12 jam Inj. Ketorolac 30 mg/ 8 jam Inj. Ranitidin 50 mg/ 12 jam Phenytoin 200 mg/ 12 jam Acarbose 50 mg/ 8 jam Asam folat 1 mg/ 12 jam
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Transcript of FU BU 1 Okt 2015
FOLLOW UP PASIEN DI BURN UNITIdentitas : Ngatmini, P, 45 thn, 1736977, 60kgDiagnosis : Vulnus Granulosum 4% TBSA ec Combustio post STSG H+37 post release kontraktur, STSG,
FTSG H+6Tanggal : 1 Oktober 2015HariKe- : 62
OBJEKTIF
Tgl 1 Oktober 2015 (05.00)S : Demam (-), kejang (-), nyeri (+) berkurang, VAS = 2-3O : KU sedang, CM
Vital Sign :BP : 120/70 mmHgHR : 84 x/mntRR : 18 x/mntT : 36,9°CMAP : 87
Assessment - Vulnus Granulosum 4% TBSA ec
Combustio- Post debridement + STSG
(6/8/2015)- Post release kontraktur + STSG
+FTSG (25/9/2015)
IWL= (25+4%)x1.58x24jam= 47.4x24= 1100 cc
Kebutuhan Cairan= (1500xTBSA)+IWL=(1500x1,58) + 1138 cc= 3508 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x4)=1660 kkal/24jam
PERKEMBANGAN
28.9.2015Hb 10,1 AE 3.46AL 8,97 AT 344HCT 29,6Alb 3,22 GDS 81Na 136 K 3.2Cl 103
26.9.2015Hb 10,3 AE 3.49AL 8,4 AT 385HCT 29,9Alb 3,03 GDS 231Na 135 K 3.6Cl 103
24.9.2015Hb 11.3 AE 3.87AL 7.31 AT 406HCT 33 PPT 13.8APTT 25.4 INR 1.0Alb 3,54 BUN 11.6Crea 0.49 GDS 171Na 137 K 3.9Cl 104
18.9.2015Alb 3,8 AL 6,47OT 18 AE 3,77PT 29 Hb 11BUN 13,5 Hct 32,2Cr 0,64 AT 443Na 136K 3,8Cl 101
MASALAH
Penyembuhan luka
Balance Cairan :CM : 2950 cc/24 jamCK : 2350 cc/24 jamIWL : 1100 cc/24 jamBC : -500 cc/24 jamBC kumulatif : -15 ccDiuresis: 1,63 cc/ kgBB/ jamUO : 350 cc/ 3 jam terakhir
Plan Awasi KU/VS/BC Inj. Ceftriaxon 1 g/ 12 jam Inj. Ketorolac 30 mg/ 8 jam Inj. Ranitidin 50 mg/ 12 jam Phenytoin 200 mg/ 12 jam Acarbose 50 mg/ 8 jam Asam folat 1 mg/ 12 jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Sunardi, L, 56 thn, 1736605, 60 kg Diagnosis : Combustio gr II-III25% tereduksi 21 % sisa 4% ec Api BensinTanggal : 1 Oktober 2015Hari Ke- : 74
OBJEKTIF
Tgl 1 Oktober 2015 (05.00)S : Demam (-), nyeri minimalVAS = 2-3O : KU sedang, CM
Vital Sign :BP : 130/80mmHgHR : 72 x/mntRR : 16 x/mntT : 36,8 °CMAP : 97
Assessment - Combustio gr II-III25% tereduksi
20 % sisa 5% ec Api Bensin
IWL= (25+%LB)xTBSAx24= (25+4)x1,62x24= 1128 cc/24 jam
Kebutuhan Cairan= (1500xTBSA)+IWL= 2430 cc + 1166= 3596 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x4)=1660 kkal
PERKEMBANGAN
28.9.2015Hb 12,7 AE 4,59AL 12,5 AT 532HCT 39,3Alb 4,23 Na 144 K 3,8Cl 102
26.09.2015SGOT 18 GDP 202SGPT 21 Chol total 221BUN 16,3 HDL 61Creat 0,66 Trygliserid 171As. Urat 6,2 LDL 155
10.09.2015Alb 4,06 AL 10,39BUN 12,1 AE 4,25Creat 0,78 Hb 11,9SGOT 23 HMT 36,4SGPT 16 AT 553Na 139K 4,23Cl 97,1
3.09.2015AL 9,07AE 5,84 Hb 14,8Hct 43,1 AL 9,07AT 192
MASALAH
Penyembuhan luka
Balance Cairan :CM : 2650 cc/24 jamCK : 800 cc/24 jamIWL : 700 cc/24 jamBC : +1150 cc/24 jamBC kumulatif : +6660 ccDiuresis: 0,56 cc/ kgBB/ jamUO : 600 cc/12 jam
Plan Awasi KU/VS/BC Cefadroxyl 500mg/ 12 jam As. Mefenamat 500 mg/ 8 jam Ranitidine 150 mg/ 12 jam Vit. B Complex 1 tab/ 12jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cmDiagnosis : Combustio grade II 10%, grade III 15%Tanggal : 1 Oktober 2015Hari Ke- : 27
OBJEKTIF
Tgl 1 Oktober 2015 (05.00)S : Nyeri (-), demam (-), diare (-)O : KU sedang, cm
Vital SignBP : 120/70 mmHgHR : 108 x/mntRR : 22 x/mntT : 37,2 0CMAP : 87
Assessment - Combustio grade II 15 %, grade
III 18 % ec. bara api- Anemia- Syok septik
TBSA = V21x125/3600 = 0,85
IWL = (25+%LB)xTBSAx24= (25+25)x0,85x24= 1020
Kebutuhan cairan= (1500xTBSA)+IWL=(1500x0,85)+1020= 2295cc/24jam= 96 cc/jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x21)+(40x25)=525+1000=1525 kkal/24jam
PERKEMBANGAN
29.9.2015Alb 2,88AL 12,15Eri 3,65Hb 10,4 Hct 29,9 AT 226
28.9.2015Hb 10,6 AE 3,74AL 14,45 AT 333HCT 31,5Alb 2,36 GDS 100Na 133 K 4,3Cl 102
26.9.2015Alb 2,6 Ca 1,96Al 18,3Hb 10,6GDS 102 Hct 31,6Na 132 At 415K 3,9Cl 102
25.9.2015Alb 2,52 Ca 1,96BUN 9,5 Al 27,99Cre 0,28 Hb 7,2GDS 91 Hct 22,2Na 130,6 At 423K 4,97Cl 96
MASALAH
NyeriAnemiaHipoalbuminemiaPenyembuhan luka
Balance Cairan :CM : 2480 cc/ 24 jamCK : 2180 cc/ 24 jamIWL : 1020 cc/ 24jam BC : -720 cc/24 jamBC kumulatif : ccDiuresis: 4,33 cc/kgBB/jamUO: 350 cc/ 2 jam terakhir
Plan Awasi KU/VS/BC Inj. Imipenem 500 mg/ 6jam Inj. Mikamin 80 mg/ 24 jam Inj. Fentanyl 1 mcg/ kgBB/ jam Inj. Paracetamol 300 mg/ 6 jam RF 2 ml/ jam AA 10% 9 ml/ jam Chloramphenicol zalf 2 dd ue Propanolol 4,5 mg/ 8jam Zinc 20 mg/ 24 jam Kapsul NaCl 500 mg/ 8 jam Vip Albumin 1 tab/ 8 jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Radiyem, 1742945, 45 tahun, 55 Kg, 155 cmDiagnosis : Combustio grade II 29% ec Api tereduksi 16% sisa 13 %Tanggal : 1 Oktober 2015Hari Ke- : 14
OBJEKTIF
Tgl 1 Oktober 2015 (05.00)S : Nyeri (+), demam (-)O : KU sedang, CM
Vital Sign :BP : 120/60 mmHgHR : 96 x/mntRR : 20 x/mntT : 37,2 CMAP : 80
Assessment - Combustio grade II 29% ec Api
tereduksi 16% sisa 13 %TBSA = V55x155/3600 = 1,5
IWL = (25+%LB)xTBSAx24= (25+13)x1,5x24= 1368/24 jam= 57 cc/jam
Kebutuhan cairan= (1500xTBSA) + IWL= (1500x1,5) + 1368= 2250 + 1368= 3618 cc/24 jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x55)+(40x13)=1375 + 520=1895 kkal/24jam
PERKEMBANGAN
28.9.2015Hb 11 AE 3,81AL 15,88 AT 443HCT 32,6Alb 3,15 Na 131 K 4,3Cl 99
26.9.2015Alb 3,11 Al 13,8Hb 11,3Hct 3,2At 372Na 134K 4,2Cl 103
25.9.2015Alb 2,82 Al 16,09BUN 11 Hb 10,6Crea 0,41 Hct 32,1GDS 131 At 332Na 135K 3,8Cl 102
22.9.2015Alb 2,43Cl 98BUN 10,9 AL 13,9Creat 0,64Hb 11,9GDS 158 AE 4,03Na 131Hmt 36K 4,4AT 467
20.9.2015Alb 2,59 Na 134,4SGOT 19 K 3,86SGPT 25 Cl 102BUN 6,10 AL 13,95Creat 0,57 AE 4,2GDS 164 Hb 13,1 HMT 38 AT 410
MASALAH
NyeriPenyembuhan luka
Balance Cairan :CM : 2550 cc/24 jam CK : 1590 cc/24 jam IWL : 1368 cc/ 24 jam BC : -408 cc/24 jamBC kumulatif : -1708 ccDiuresis: 1,2 cc/kgBB/jamUO: 350 cc/ 7 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 2X500 mg As Mefenamat 3X500mg Ranitidin 2X150mg B Complex 2X1tab
FOLLOW UP PASIEN DI BURN UNITIdentitas : Izzatul Jannah, 00732175, 6 tahun, 25 Kg, 120 cmDiagnosis : Combustio grade II 22% ec air panasTanggal : 1 Oktober 2015Hari Ke- : 4
OBJEKTIF
Tgl 1 Oktober 2015 (05.00)S : Nyeri (+), demam (+)O : KU sedang, CM
Vital Sign :BP : 90/60 mmHgHR : 123 x/mntRR : 24 x/mntT : 37,9 CMAP : 70
Assessment Combustio grade II 22% ec air panas
TBSA = V25x120/3600 = 0,91
IWL = (25 + % LB) x TBSA x 24= (25 + 22) x 0,91 x 24= 1026,48 / 24 jam= 42,77 cc/jam
Kebutuhan cairan= (1500 x TBSA) + IWL= (1500 x 0,91) + 1026,48= 1365 + 1026,48= 2391,48 cc/24 jam
Kebutuhan kalori=(25 x BB) + (40 x % LB)=(25 x 25)+(40 x 22)= 625 + 880= 1505 kkal/24jam
PERKEMBANGAN
30.9.2015Alb 2,9 K 4,38GDS 105 Cl 106Na 137 Ca 2,02
29.9.2015GDS 58 AL 14,14Na 136 Hb 11K 3,2 Eri 4,14Cl 107 Hct 32AT 402
28.9.2015Hb 10,6 AE 3.91AL 15,85 AT 496HCT 31,3Alb 2,37 GDS 419Na 130 K 8,3Cl 101PO2 155,8PCO2 39,1pH 7,27SO2 98,9cHCO3 17,5BE-8,3AaDO2 47,5
27.9.2015Alb 3,04 Hb 13,1SGOT 21 HMT 39,2SGPT 22 AT 344BUN 2,5 PPT 15,5Creat 0,41 Kontrol PPT 11,3GDS 123 APTT 33,1Na 134,1 Kontrol APTT 29,6K 3,52 INR 1,15Cl 103AL 12,12AE 4,91
MASALAH
NyeriPenyembuhan lukaHipoalbuminemia
Balance Cairan :CM : 2314 cc/ 24 jamCK : 1220 cc/ 24 jamIWL : 1029 cc/ 24 jamBC : +65 cc/ 24 jamBC kumulatif : +709 ccDiuresis: 2,03 cc/ kgBB/ jamUO: 150 cc/ 3 jam terakhir
Plan Awasi KU/VS/BC Inj. Ceftriaxone 1250 mg/ 12 jam Inj. Fentanyl 0,5 mcg/kgBB/jam Inj. Paracetamol 250 mg/ 8 jam Propanolol 5 mg/8jam Diet TKTP
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