FU BU 3 September 2015
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FOLLOW UP PASIEN DI BURN UNIT Identitas : Yahwa Nafisa, 1729116, 19 bulan, 9 kg Diagnosis : Vulnus granulosum ec Combustio Gr II-III 16,5% ec. Bara api, rhinofaringitis akut, anemia, hipoalbumin perbaikan, post STSG H-35 Tanggal : 3 September 2015 Hari Ke- : 106
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Transcript of FU BU 3 September 2015
FOLLOW UP PASIEN DI BURN UNITIdentitas : Yahwa Nafisa, 1729116, 19 bulan, 9 kgDiagnosis : Vulnus granulosum ec Combustio Gr II-III 16,5% ec. Bara api, rhinofaringitis akut,
anemia, hipoalbumin perbaikan, post STSG H-35Tanggal : 3 September 2015Hari Ke- : 106
FOLLOW UP PASIEN DI BURN UNITIdentitas : Arini Husnayeni, P, 19 thn, 1733726, BB 45 kg, TB 150 cmDiagnosis : Vulnus granulosum e/c Combustio Gr II-III 29% tereduksi 27% sisa 2%, hipoalbuminemia
perbaikan, Anemia perbaikan, AutismTanggal : 3 September 2015
OBJEKTIF
Tgl 3 September 2015 (05.00)S : Demam (-), diare (-), muntah(-)O : KU sedang, CM
Vital Sign :BP : -HR : 120 x/mntRR : 32 x/mntT : 36,80C
Assessment - Vulnus granulosum ec Combustio
Gr II-III 16,5% ec. Bara api- Rhinofaringitis akut- Anemia membaik- Hipoalbuminemiaperbaikan- Post STSG H-35
Kebutuhan cairan= (1500xTBSA)+IWL=(1500x0,4)+375= 998cc/24jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x9)+(40x16,5)=220+660=885 kkal/24jam
PERKEMBANGAN
27.08.2015AL 10,67 Hb 9,2 AT 332
24.08.2015Alb 3,32 Hb 9,2Na 136 Hct 29,9K 5,5 Cl 104 AT 1154Ca 2,5
21.8.2015Alb 2,22 BUN 4,4Cr 0,41 Na 134,8Cl 101 K 4,53Cal 2,16 Hb 9,6AL 10,74 AT 1003CRP kuant >150Procalcitonin 0,25Kultur darah –
20.8.2015Feses rutinpH 7,5Sudan III –Sisa tumbuhan +
18.08.2015Urinalisis:pH 5,5BJ 1010Warna colourlessEr 8,Leu 4,8Sel epitel 5,1Silinder 0,00Bakteri 35,4Kristal 0,1Small round cell 3,5Konduktivitas 3,7
17.08.2015Albumin : 3.84Na/K/Cl : 140/7.2/107Hb : 10.2AL : 8.1AT : 549AE : 3.62Hct : 32,6
MASALAH
Penyembuhan lukaAnemia
Balance Cairan :CM : 840 cc/24 jam CK : 480 cc/24 jam IWL : 375 cc/24jam BC : -15cc/24 jamBC kumulatif : -20 ccDiuresis: 1 cc/kgBB/jamUO: 70 cc/6 jam terakhir
Plan Awasi KU/VS/BC Propanolol 3mg/ 8 jam Salbutamol syr 3x1/2 cth Oralit k/p
HariKe- : 67
FOLLOW UP PASIEN DI BURN UNITIdentitas : Ngatmini, P, 45 thn, 1736977, 60kgDiagnosis : Vulnus Granulosum 5% TBSA ec Combustio post STSG H+25Tanggal : 3 September 2015HariKe- : 34
OBJEKTIF
Tgl 3 September 2015 (05.00)S : Demam (-), sesak (-)O : KU lemah, CM
Vital Sign :BP : 140/80mmHg HR : 92 x/mntRR : 20 x/mntTemp : 37,1°CMAP : 100Assessment Vulnus granulosum e/c
Combustio Gr II-III 29% tereduksi 27% sisa 2%
Hipoalbuminemia membaik Anemia perbaikan Autism
IWL= (25+%LB)xTBSA = (25+2)x1,37 = 36,99 cc/ jam
Keb Cairan= (1500xTBSA)+IWL= 2055 cc + 877,76 cc= 2942,76 cc
Koreksi kebutuhan cairan; balance nol per jam= IWL + UO cc/jam= 37 cc + UO cc/ jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=1125 + 80=1205 kkal
PERKEMBANGAN
27.08.2015Alb 4,4 Na 140 K 5,00Cl 99 AL 3,70 Hb 11,2 AT 487
26.08.2015Alb 4.25Na 137K 4.40Cl 97AL 4.01AE 4.02HB 11Hct 35.1AT 548
24.08.2015Alb 4,0 Hct 33,9Na 132 AT 517K 5,0Cl 97AL 5,28Er 3,88Hb 10,7
20.8.15Alb 3,72 BUN 7,3Cr 0,31 Na 139K 3,8 Cl 101Hb 9,4 AL 3,59AT 146
19.08.2015Urinalisa;Glu: (-) Prot: (+)Bil : (-) Urobil: (1+)pH: 7,5
17.08.2015Alb 3.66AL 4.23AE 3.53HB 9.7Hmt 30.9AT 430Na/K/Cl 140/3.10/102
15.8.2015Alb 3,6 AL 4,9 AE 3,1Hb 8,5 Hmt 27,0AT 431 Na 138K 3,10Cl 102
MASALAH
Penyembuhan luka
Balance CairanCM : 1325 cc/24 jam CK : 430 cc/24 jam IWL : 650 cc/24 jam BC : +245 cc/24 jamBC kumulatif : +4050 ccDiuresis : 0,39 cc/kgBB/jamUO : 150cc/6 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 2x500 mg Asam mefenamat 3x500 mg Ranitidine 2x150 mg Vit. B complex 2x1 Vit. C 1x1 Sucralfate 10cc/8jam
OBJEKTIF
Tgl 3 September 2015 (05.00)S :Demam (-), batuk (-), nyeri (+) berkurang, VAS = 2-3O : KU sedang, CM
Vital Sign :BP : 120/70 mmHgHR : 84 x/mntRR : 18 x/mntT : 37,2°CMAP : 87
Assessment - Vulnus Granulosum 5% TBSA ec
Combustio post STSG H+25
IWL= (25+5%)x1.58x24jam= 47.4x24= 1138 cc
Kebutuhan Cairan= (1500xTBSA)+IWL=(1500x1,58) + 1668 cc= 4038 cc/24 jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x19)=2260kkal/24jam
PERKEMBANGAN
1.9.2015Alb 3,7 Na 142 K 4,15 Cl 102 AL 5,7 Hb 11,0 Hct 32,6 AT 498
27.8.2015Alb 2,88 Na 142 K 4,15 Cl 102 AL 6,86 Hb 10.3 Hct 29.6 AT 506
24.8.2015Alb 3,61 Eri 3,5 Na 135 Hb 10,2K 3,3 Hct 29,9 Cl 101 AT 600AL 6,24
20.8.15Alb 3,98 BUN 20,1Cr 0,62 Na 137K 3,6 Cl 99Hb 10,3 AL 7,09AT 693
17.08.2015Alb 3.64Na/K/Cl 135/4.8/103Hb 9.1AL 6.9AE 3.18AT 490
14.08.2015Alb3,77 Hb 10,6 Na 130 Hct 32,1 K 6,37 AT 432Cl 98 AL 8,09 Eri 3,66
12.08.2015Alb 3,89Na/K/Cl 135/4,4/103Hb 9,3 Hct 27,8 AE 3,26AL 9,81 AT 401
MASALAH
Penyembuhan luka
Balance Cairan :CM : 3000 cc/24 jam CK : 2350 cc/24 jam IWL : 1138 cc/24 jam BC : -488 cc/24 jamBC kumulatif : +1586 ccDiuresis: 1,63 cc/kgBB/jamUO : 300 cc/4 jam terakhir
Plan Awasi KU/VS/BC Cefadroxil 2x500mg Asam mefenamat 3x500mg Ranitidine 2x150mg OBH Syr 3x1 C Phenytoin 150mg/12 jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Sunardi, L, 56 thn, 1736605, 60 kg Diagnosis : Combustio gr II-III25% tereduksi 20 % sisa 5% ec Api Bensin, Dispepsia, Anemia,
Hipoalbuminemia perbaikanTanggal : 3 september 2015
Hari Ke- : 36
OBJEKTIF
Tgl 3 September 2015 (05.00)S : Demam (-) nyeri minimal, gatal di bagian dada dan perut (+)VAS = 3O : KUsedang, CM
Vital Sign :BP : 110/60 mmHgHR : 72 x/mntRR : 16 x/mntT : 36,8°CMAP : 77
Assessment - Combustio gr II-III25% tereduksi
20 % sisa 5% ec Api Bensin- Dispepsia perbaikan- Anemia dlm perbaikan- Hipoalbumin dlm perbaikan
IWL= (25+%LB)xTBSAx24= (25+5)x1,62x24= 1166cc/24 jam
Kebutuhan Cairan= (1500xTBSA)+IWL= 2430 cc + 1166= 3596 cc/24 jam
Koreksi kebutuhan cairan; balance nol= IWL + UO cc/jam= 49 cc/jam + UO cc/jam
Kebutuhan Kalori=(25xBB)+(40x%LB)=(25x60)+(40x5)=1700 kkal
PERKEMBANGAN
31.08.2015AL 9,7BUN 5,8 AE 3,3Creat 0,7 Hb 9,6Na 133 Hct 29,1K 4,4 AT 581Cl 97
30.08.2015Alb 3,33Na 133K 4,8Cl 95
28.08.2015Alb 2,63 AL 12,16BUN 15,5 AE 3,62Creat 1,25 Hb 12,0Na 119,8HMT 33,1K 4,73 AT 223Cl 85
27.08.2015Alb 3,58 Na 135 K 5,2 Cl 95 AL 10,78 Hb 9,7 Hct 29,5% AT 503 26.8.2015OT 16PT 24BUN 4.4Cre 0.79
24.8.2015Alb 3,53 Hb 10,2Na 130 Hct 308K 4,3 AT 543Cl 93AL 12,12Eri 359
MASALAH
Penyembuhan luka
Balance Cairan :CM : 2500 cc/24 jamCK : 2300 cc/24 jamIWL : 1166 cc/24 jamBC : -966 cc/24 jamBC kumulatif : -34 ccDiuresis: 1,59 cc/kgBB/jamUO : 1000 cc/5 jam terakhir
Plan Awasi KU/VS/BC Cefadroxyl 500mg/ 12 jam Asam Mefenamat 500 mg/ 8
jam Ranitidine 150 mg/ 12 jam Vit B complex 1tab/12jam Kapsul garam 3x1
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Sukrismon, L, 17 thn, 1730334, 60 kg Diagnosis : Combustio gr II 35.5 %, gr III 14 %, SIRS, HipoalbuminemiaTanggal : 3 September 2015Hari Ke- : 8
OBJEKTIF
Tgl 3 September 2015 (05.00)S : Demam (+) nyeri (+) minimalVAS = 3O : KU sedang, CM
Vital Sign :BP : 102/55 mmHgHR : 109 x/mntRR : 20 x/mntT : 38,5°CMAP : 71
Assessment - Combustio gr II 35.5 %, gr III 14 %
ec listrik- SIRS- Hipoalbuminemia
IWL= (25+%LB)xTBSAx24= 74,5x1,65x24= 2950cc/24 jam
Kebutuhan Cairan= (1500xTBSA)+IWL= 2430 cc + 2950= 5380 cc/24 jam
PERKEMBANGAN
2.9.2015Alb 1,86 AL 13,76GDS 71 AE 3,98Na 131,9 Hb 11,9K 3,31 Hct 33,5Cl 99 AT 179
31.08.2015Alb 2,6 AL 6,2BUN 8,7 AE 4,3Creat 0,6 Hb 12,8Na 129 Hct 37,1K 3,6 AT 111Cl 100
29.08.2015Alb 2,79
27.08.2015Alb 2,85 SGOT 58 SGPT 79BUN 9,4 CREAT 0,81 GDS 129Na 130 K 4,40 Cl 101AL 7,26 Hb 15,9 Hct 46,6AT 166
26.8.2015HB 17.4AL 10.9AT 373BUN 15.6Cr 1.08Alb 5.39OT 225PT 114Na 140K 3.6Cl 100
MASALAH
Penyembuhan lukaSIRSHipoalbuminemia
Balance Cairan :CM : 9079 cc/24 jamCK : 6140 cc/24 jamIWL : 2829 cc/24 jamBC : +110 cc/24 jamBC kumulatif : +92 ccDiuresis: 1,96 cc/kgBB/jamUO : 200 cc/ 1jam terakhir
Plan Awasi KU/VS Balance cairan nol per jam Inj Ceftriaxone 1gr/12 jam Inj Fentanyl 30 mcq/jam (titrasi) Inj. Ranitidine 50 mg/12 jam Inj. Paracetamol 1 gr/8 jam Inf. Combiplex:RL:D5%:albumin
2:2:1:1 60 cc/jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cmDiagnosis : Combustio grade II 10%, grade III 15%Tanggal : 3 September 2015Hari Ke- : 0
OBJEKTIF
Tgl 3 September 2015 (05.00)S : Nyeri (+), demam (-), diare (-), muntah(-)O : KU sedang, CM
Vital Sign :BP : 135/79 mmHgHR : 150 x/mntRR : 24 x/mntT : 36,80C
Assessment - Combustio grade II 10%, grade III
15% ec. bara api
TBSA = V21x125/3600 = 0,85
IWL = (25+%LB)xTBSAx24= (25+31)x0,85x24= 1142 Kebutuhan cairan= (1500xTBSA)+IWL=(1500x0,85)+1142= 2417 cc/24jam= 101 cc/jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x21)+(40x35)=525+1400=1925 kkal/24jam
PERKEMBANGAN
3.9.2015Alb 1,86 HbsAg OT 63 AL 36PT 30 AE 5,74BUN 10,3 Hb 14,5Cr 0,57 Hct 44,3 GDS 138 AT 294Na 135,2 PPT 19,7K 4,25 INR 1,56Cl 105 kPPT 13,1APTT 43,1 kAPTT 32,5
MASALAH
NyeriKebutuhan cairan
Balance Cairan :CM : 325 cc/4 jam CK : 100 cc/4 jam IWL : 190 cc/24jam BC : +35 cc/24 jamBC kumulatif : +35 ccDiuresis: 1,19 cc/kgBB/jamUO: 100 cc/4 jam terakhir
Plan Awasi KU/VS/BC Inj. fentanyl 1mcg/kgBB/jam Inj. ranitidine 25 mg/12 jam
