FU BU 6 November 2015
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FOLLOW UP PASIEN DI BURN UNIT Identitas : Asep Sulistyo, L, 17 thn, 1744725 Diagnosis : Combustio gr II 5% ec listrik Tanggal : 6 November 2015 Hari Ke- : 34 OBJEKTIF Tgl 6 November 2015 (05.00) S : Demam (-), nyeri(+) O: KU sedang, CM Vital Sign : BP : 110/80mmHg HR : 92 x/mnt RR : 20 x/mnt T : 37,3°C MAP : 90 Assessment - Combustio gr II 5% ec listrik IWL = (25+%LB)xTBSAx24 = (25+5)x1,5x24 = 1080 cc/24 jam KebutuhanCairan = (1500xTBSA) + IWL = (1500x1,5) + 1080 cc = 3330 cc/24 jam PERKEMBANGAN 2.11.15 Alb 3,32 SGOT 13 SGPT 12 Cr 0,58 GDS 76 Na 135 K 3,80 Cl 101 AL 12,56 Eri 3,69 Hb 10,4 Hct 31,5 AT 728 26.10.15 Alb 3,34 Hb 10,9 AE 3,67 HT 32,3 AL 9,73 AT 774 22.10.15 Alb 3,05 Hb 11,5 AL 16,14 AT 644 Na 134 K 5,2 Cl 102 GDS 85 BUN 13,7 Cr 0,65 20/10/2015 Alb 2,86 AL 12,07 Na 134 Hb 11,6 K 4,8 Hmt 32,6 Cl101 AT 561 18/10/2015 Alb 3,03 Al 16,00 OT/PT 52/67 Hb 12,3 BUN 18,60 Ht MASALAH Nyeri Penyembuhan luka Balance Cairan : CM : 4022 cc/24 jam CK : 2700 cc/24 jam IWL : 1088 cc/24 jam BC : +234 cc/24 jam OU : 2,25 cc/kgBB/jam Plan Awasi KU/VS/BC Fosfomycine 1 gr/12 jam Paracetamol 350 mg /8jam kp Vit c 1tab /8 jam
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Transcript of FU BU 6 November 2015
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Asep Sulistyo, L, 17 thn, 1744725Diagnosis : Combustio gr II 5% ec listrikTanggal : 6 November 2015Hari Ke- : 34
OBJEKTIF
Tgl 6 November 2015 (05.00)S : Demam (-), nyeri(+)O: KU sedang, CM
Vital Sign :BP : 110/80mmHgHR : 92 x/mntRR : 20 x/mntT : 37,3°CMAP : 90
Assessment- Combustio gr II 5% ec listrik
IWL= (25+%LB)xTBSAx24= (25+5)x1,5x24= 1080 cc/24 jam
KebutuhanCairan= (1500xTBSA) + IWL= (1500x1,5) + 1080 cc= 3330 cc/24 jam
PERKEMBANGAN
2.11.15Alb 3,32 SGOT 13 SGPT 12Cr 0,58 GDS 76 Na 135K 3,80 Cl 101 AL 12,56Eri 3,69 Hb 10,4 Hct 31,5AT 728
26.10.15Alb 3,34 Hb 10,9 AE 3,67HT 32,3 AL 9,73 AT 774
22.10.15Alb 3,05 Hb 11,5AL 16,14 AT 644Na 134 K 5,2Cl 102 GDS 85BUN 13,7 Cr 0,65
20/10/2015Alb 2,86 AL 12,07Na 134 Hb 11,6K 4,8 Hmt 32,6Cl101 AT 561
18/10/2015Alb 3,03 Al 16,00OT/PT 52/67 Hb 12,3BUN 18,60 Ht 37,6Cr 0,77 At 597GDS 130Na 132,2K 5,03Cl 2,17
MASALAH
NyeriPenyembuhan luka
Balance Cairan :CM : 4022 cc/24 jamCK : 2700 cc/24 jamIWL : 1088 cc/24 jamBC : +234 cc/24 jamOU : 2,25 cc/kgBB/jam
Plan Awasi KU/VS/BC Fosfomycine 1 gr/12 jam Paracetamol 350 mg /8jam kp Vit c 1tab /8 jam
FOLLOW UP PASIEN DI BURN UNIT
Identitas : Tugiman, 1747039, 31 tahun, 60 kg, 165 cmDiagnosis : Combustio grade II 15% ec listrikTanggal : 6 November 2015Hari Ke- : 17
FOLLOW UP PASIEN DI BURN UNITIdentitas : Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cmDiagnosis : Combustio grade II 17%Tanggal : 6 November 2015Hari Ke- : 61
OBJEKTIF
Tgl 6 November 2015 (05.00)S : Nyeri (+), demam (+)O : KU sedang, CM
Vital SignBP : 158/78 mmHgHR : 110 x/mntRR : 20 x/mntT : 38,3 0CMAP : 105
AssessmentCombustio grade II 17% ec listrik
TBSA= V60x165/3600 = 1,66
IWL= (25+%LB)xTBSAx24= (25+17)x1,66x24= 1673 cc/24jam
Kebutuhancairan= (1500xTBSA)+1673=(1500x1,66)+1673= 4163 cc/24jam= 170 cc/jam
Kebutuhankalori=(25xBB)+(40x%LB)=(25x60)+(40x17)=1500 +680=2180kkal/24jam
Saturasi tangan kanan/kiri :Jari 1 97%/97%Jari 2 98%/97%Jari 3 97%/96%Jari 4 98%/98%Jari 5 98%/98%
PERKEMBANGAN
5.11.2015Alb 2,8 Na 144,8OT 99 K 3,15PT 80 Cl 106BUN 18,6 AL 12,9Cr 1,11 AE 3,6GDS 69 Hb 10,1Hct 29,2 AT 371
4.11.2015Alb 2,17 Hb 10,2Na 138 At 286K 3,20Cl 106Al 11,45
2.11.2015Alb 2,31 SGOT 55 SGPT 54BUN 32,0 Cr 1,60 Na 139K 3,00 Cl 107 AL 15,92Eri 3,70 Hb 10,3 Hct 29,8AT 158
1.11.2015Alb 3,08
29.10.2015Alb 2,21Hb 11,4Hmt 32,6AE 3,93AL 17,92Na 131Cl 104K 3,50SGOT 122,0SGPT 169GDS97,0
MASALAH
NyeriPenyembuhan lukaHipoalbuminemiaPeningkatan enzim transaminaseHipertensi
Balance Cairan :CM : 4250 cc/24 jamCK : 3600 cc/24 jamIWL : 1592 cc/24jamBC : -942 cc/24 jamUO : 2,5 cc/kgBB/jam
Plan Awasi KU/VS/BC Inj. Ranitidine 50 mg/12 jam Inj. Ketorolac 30 mg/8jam Inj. SNMC 1amp/12 jam Inj. Vit C 1 amp/12 jam Inf. Albumin 20% 100 cc/24 jam Curcuma 2x1 tab Sistenol 3x1 tab Kapsul garam 3x1 cap Amlodipin 1x10 mg Captopril 3x25 mg
FOLLOW UP PASIEN DI BURN UNITIdentitas : Usi Amri, 1747634, 31 tahun, 60kgDiagnosis : ODS trauma okuli, combustio gr I 19 % eccairankimia, combustio gr 2 % eccairankimiaTanggal : 6 November 2015Hari Ke- : 12
OBJEKTIF
Tgl 6 November 2015 (05.00)S : Nyeri (+), demam (+)O : KU sedang, CM
Vital SignBP : 120/70 mmHgHR : 124 x/mntRR : 24 x/mntT : 35,8 0CMAP : 87
Assessment- Combustio grade II 25% ec bara
api
TBSA= V21x125/3600 = 0,85
IWL= (25+%LB)xTBSAx24= (25+25)x0,85x24= 1020
Kebutuhancairan= (1500xTBSA)+IWL=(1500x0,85)+1020= 2295cc/24jam= 96 cc/jam
Kebutuhankalori=(25xBB)+(40x%LB)=(25x21)+(40x25)=525+1000=1525kkal/24jam
PERKEMBANGAN
5.11.2015Alb 2,76 AL 8,29OT 13 AE 2,98PT 7 Hb 8,1BUN 5,5 Hct 24,5Cr 0,2 AT 399CRP 131
2.11.2015Alb 2,40 SGOT 12,0 SGPT 6BUN 5,2 Cr 0,19 GDS 85Na 133 K 3,60 Cl 104Ca 2,0 AL 7,66 AE 3,49Hb 9,8 Hct 29,5 AT 110
30.10.2015Procalsitonin 11,53
27.10.2015Alb 3,13
27.10.2015Alb 3,12
26.10.2015Alb 2,38 AL 23,66Na 137 Hb 9,8K 3,5 Hmt 29,3Cl107 AT 471
MASALAH
NyeriPenyembuhan lukaHipoalbuminemiaAnemiaSepsis
Balance Cairan :CM : 1800,5 cc/24 jamCK : 710 cc/24 jamIWL : 972 cc/24jamBC : 217,5 cc/24 jamUO : 1,4 cc/kgBB/jam
Plan Awasi KU/VS/BC Inj. Meropenem750 mg/8jam Inj. Chloramphenicol 500 mg/6
jam Inj. Paracetamol 5 ml/ jam drip
continue Inj. Ranitidine 25 mg/ 12 jam Inj.Vit C 1/2 Amp/24 jam AA 17 cc/jam Propanolol 4,5 mg/8 jam Cetirizine 5 mg/12 jam Alb 25% 20ml 2 cc/jam
FOLLOW UP PASIEN DI BURN UNITIdentitas : Kalman Asyam, 1748580, 2tahun, 10 kgDiagnosis : Combustio gr III 30 % ec air panas, SepsisTanggal : 6 November 2015Hari Ke- : 3
OBJEKTIF
Tgl 6 November 2015 (05.00)S : Nyeri (+), demam (-)O : KU sedang, CM
Vital SignBP : 130/70mmHgHR : 104x/mntRR : 20x/mntT : 37,4 0CMAP : 90
AssessmentODS trauma okuli,combustio gr I 19 % ec cairan kimia,combustio gr III 2 % ec cairan kimia
IWL= (25+%LB)xTBSAx24= (25+16)x1,587x24= 1.561
Kebutuhancairan= 50 cc/kgbb/hari= 60X60 = 3000cc/24 jam=1000 cc oral= 2000 cc infus /24 jam = 83cc/jam
Kebutuhankalori=(25xBB)+(40x%LB)=(25x58)+(40x19)=1400+760=2160kkal/24jam
PERKEMBANGAN
5.11.2015Alb 4,06Na 143,6K 4,26Cl 99AL 39,37AE 5,22Hb 15,6Hct 45,2AT 309
2.11.2015Alb 3,94 SGOT 28 SGPT 58BUN 14,0 Cr 0,80 GDS 174Na 142 K 4,50 Cl 102AL 29,92 Eri 5,26 Hb 15,5Hct 45,1 AT 173
30.10.2015Alb 3,38Cr 0,87Na 134K 2,9Cl 101Hb 14,9Hmt 43,1AT 147AE 4,9AL 23,97GDS 188,0
26/10/15Alb 4,38 OT 18PT 20 BUN 9,9Cr 0,79 GDS 123Na 140 K 4,30Cl 103PPT 13(14,8)INR 0,93APTT 27,2(28,4)
MASALAH
NyeriPenyembuhan luka
Balance Cairan :CM : 4000 cc/24 jamCK : 2200 cc/24 jamIWL : 1561 cc/24jamBC : +239 cc/24jamUO : 1,67 cc/kgBB/jam
Plan Awasi KU/VS/BC Methilprednisolon 16 mg II-II-0 Cotrimoxazole 960 mg/12 jam Vit C 1000 mg/12 jam Oksitetrasiklin ED 1 ODS/8 jam SA 1 % ED 1 ODS/12 jam Cendo lyteers 1 tetes/20 menit
FOLLOW UP PASIEN DI BURN UNITIdentitas : Heri Sukasno Warno, 1748257, 48tahun, 60 kgDiagnosis : Combustio gr II 9 % ec listrik, combustio gr III 1 % ec listrikTanggal : 6 November 2015Hari Ke- : 6
OBJEKTIF
Tgl 6 November 2015 (05.00)S : rewelO : KU sedang, CM
Vital SignBP :HR : 148 x/mntRR : 28 x/mntT : 36,8 0C
AssessmentCombustio gr III 30 % ec air panas,Sepsis
TBSA= 0,43
IWL= (25+%LB)xTBSAx24= (25+30)x0,43x24= 56 cc / jam = 567 / 24 jam
Kebutuhan cairan= (740 XTBSA) + IWL= (750 X 0,43) + 567= 322 + 567= 890/24jam= 37 / jam
Kebutuhan kalori=(25xBB)+(40x%LB)=(25x10)+(40x30)= 1450 kkal/24jam
PERKEMBANGAN
3.11.2015SGOT 39,00 SGPT 30BUN 6,4 Cr 0,46GDS 105 Na 141 K 3,8Cl 102 AL 9,8 AE 3,8Hb 9,8 Hct 29 AT293
MASALAH
Sepsis Anemia
Balance Cairan :CM : 1208,8 cc/24 jamCK : 950 cc/24 jamIWL : 300 cc/24jamBC : -41,2 cc/24jamUO : 3,96 cc/kgBB/jam
Plan Awasi KU/VS/BC Inj. Meropenem 400 mg/8 jam Inj. Fentanil 0,2 cc/jam Paracetamol 100mg/8 jam (Kp) Nystatin 5 cc/6 jam
OBJEKTIF
Tgl 6 November 2015 (05.00)S : Nyeri (+), demam (+)O : KU sedang, CM
Vital SignBP : 148/79 mmHgHR : 112 x/mntRR : 20 x/mntT : 38,40CMAP : 102
AssessmentCombustio gr II 9 %, gr III 1 % ec listrik, Post amputasi below elbow sinistra H1
TBSA= 1,62
IWL= (25+%LB)xTBSAx24= (25+10)x1,62x24= 56 cc / jam = 1344 / 24 jam
Kebutuhancairan= 50 cc/kgbb/hari= 60X60 = 3000cc/24 jam=1000 cc oral= 2000 cc infus /24 jam = 83cc/jam
Kebutuhankalori= (25xBB)+(40x%LB)= (25x60)+(40x10)= 1900 kkal/24jam
Saturasi tangan kanan :Jari 1 94%Jari 2 95%Jari 3 95%Jari 4 96%Jari 5 96%
PERKEMBANGAN
4.11.2015Alb 2,48 Na 129,9OT 129 K 4PT 139 Cl 102BUN 13,4 Hct 25,5Cr 0,83 AT 264AL 20,77Hb 8,7
2.11.2015Alb 2,96 SGOT 248SGPT 125 BUN 8,6 Cr 0,82GDS 130 Na 135 K 4,40Cl 102 AL 14,02 Eri 4,38Hb 12,5 Hct 35,6 AT 134
1.11.2015Alb 2,37GDS 230
31.10.2015Alb 2,25 OT 338PT 113 BUN 6,7Cr 0,80 GDS 230Na 130 K 4,2Cl 103 HbSAG(-)AL 13,05 AE 4,98HB 14,2 Ht 40,6AT 132PPT 17,9 INR 1,37Kontrl PPT 15,2 APTT 34,3Kontrol APTT 29,8
MASALAH
Nyeri Penyembuhan luka Hipoalbuminemia Peningkatan enzim transaminase Anemia
Balance Cairan :CM : 6462 cc/24 jamCK : 3800 cc/24 jamIWL : 1344 cc/24jamBC : +1318 cc/24jamUO : 2,88 cc/kgBB/jam
Plan Awasi KU/VS/BC Inj. Ceftriaxone 1 gr/12 jam Inf. Metronidazole 500 mg/8 jam Inj. Ketorolac 30 mg/ 8 jam Inj. Ranitidine 50 mg/ 8 jam Vit. C 1amp/12 jam Albumin 100 cc/24jam Sistenol 1,5 tab/8 jam
