2. Diagnosis : Combutio grade II-III 14%ec Api listriktereduksi 13% H58,post amputasi below knee dextra H58,post amputasi below elbow dextra H49,post debridement H36, post amputasi below cubiti sinistra H7,post flap regio parietal H9 3. Tanggal :11 Mei 2014 4. Harike :66 O B Y E K T I F
Tgl 11 Mei 2014 05.00 S : nyeri luka post amputasi (+) O : KU : Sedang, CM Vital sign : TD: mmhg N : x/menit R : x/menit T : 0 C
IWL = (25+%LB)xTBSAx24 = (25+ 14)x1,5 x24 = 1404cc/24 jam Kebutuhan cairan = (1500xTBSA)+IWL = (1500x1,5)+1404 = 3000 cc/ 24 jam Enteral 2654 cc Parenteral 1000 cc Kebutuhan protein = 2 g/kgBB / 24 jam = 128 gram P E R K E M B A N G A N
2/5/14 Hb 8,2 AT 526 Al 13,6 Na 142 K 3,46 Cl 100 Alb 2,84 Mg 1,95 Ca 2,05
1/5/2014 Hb 7,1 AL 12,21 AT 568 Alb 2,87 Na 144 K 3,64 Cl 101
M A S A L A H
- Nyeri - Hipoalbuminemia membaik - Anemia
Balance cairan : CM : cc/24 jam CK : cc/24 jam IWL cc/24jam BC : cc Diuresis : cc/kgBB/jam UOP 2 jam terakhir: cc
Plan : - Awasi KU/VS - Inj Ketorolac 30 mg/8 Jam(K/P) - Inj Meropenem 1gr/12jam - Inj Ranitidin 1 Amp/12 Jam - Gentamicyn zalf - Sistenol 3x1 (K/P) - Vit C 3x1 - Kebutuhan cairan 3000 cc/24 jam - Keb Protein 60-120 gram/24 jam - Mobilisasi s/d jalan
FOLLOW UP PASIEN DI BURN UNIT 1. Identitas :Muhadi, L, 45 thn, 1.67.42.54, ; BB 70kg 2. Diagnosis : Combutio grade II 15 %, III 7 %ec listrik H 69,Kompartemen sindrom post escharotomy,post disartikulasi phalanx 2,3,4 manus D H57,Post Debridement H41 3. Tanggal : 11 Mei 2014 4. Harike : 69 O B Y E K T I F
Tgl 11 Mei 2014 05.00 S : Nyeri(+), demam (-) O : KU : Sedang, CM Vital sign : TD: mmhg N : x/menit R : x/menit T : 0 C
Assesment : Combutio grade II 15 %, III 7 % eclistrik H 64,Kompartemen sindrom post escharotomy,post disartikulasi phalanx 2,3,4 manus D H52,Post Debridement H36 ARF membaik TBSA: 1,81 IWL = (25+%LB)xTBSAx24 = (25+ 7)x1,81 x24 = 1390cc/24 jam
Kebutuhan cairan =(1500x1,81)+ IWL = 2715+ 1390 = 4105 cc/24 jam Oral 3100 cc IVFD 1000cc = 42cc/jam
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram P E R K E M B A N G A N 29/4/2014 Hb 11,9 AL 7,61 Hmt 35,6 AT 419 Na 144 K 4,60 Cl 101 AST 34 ALT 62 Alb 3,46 Bun 7 Creat 1,01
20/4/2014 AL 7,5 Hb 11.4 AE 4,07 At 484 Bun 6 Creat 0,87 Alb 2,98 Na 138 K 4,03 Cl 101
19/4/14 Tigecycline = sensitive Hasil Mengindikasikan Multi Drug resistance M A S A L A H - Peningkatan enzym transaminase - Hipoalbumin membaik - Hiponatremia membaik
Balance cairan : CM : cc/24 jam CK : cc/24 jam IWL cc/24jam BC : cc Diuresis : cc/kgBB/jam UOP 2 jam terakhir: cc
Plan : Awasi KU / VS IVFD RL:KAENMg 3:Aminofluid : 1:1:1 = 42 cc/jam Diet TKTP + Ekstra PUTEL Inj. Tramadol 100mg/12 jam Sistenol 3x1 (k/p) Cetirizine 1 tab po (k/p) Rawat luka dengan burnazin Vit 3x1 Pro tutup defek
FOLLOW UP PASIEN DI BURN UNIT 1. Identitas : Riyono , L, 17 th, 1 68 21 32 , BB 58 kg 2. Diagnosis : Combutio grade II III 1 % e.c Listrik H8 Post Debridement, STSG, Escharotomy, Groin flap H1 3. Tanggal : 11 Mei 2014 4. Harike : 11 O B Y E K T I F
Tgl 11 Mei 2014 05.00 S : Nyeri(+), demam (-) O : KU : Sedang , CM Vital sign : TD: mmhg N : x/menit R : x/menit T : 0 C
Assesment : Combutio grade II III 1 % ec Listrik H8, Post Debridement,STSG, Escharotomy, Groin Flap H1 TBSA: 1,8 IWL = (25+%LB)xTBSAx24 = (25+ 1)x1,81 x24 = 1123,2cc/24 jam
Kebutuhan cairan =(1500x1,8)+ IWL = 2700+ 1123,2 = 3823,2 cc/24 jam Oral 1823,2 cc IVFD 2000cc = 83cc/jam
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram P E R K E M B A N G A N
7/5/2014 AL 9,81 Hgb 13,3 HCT 37,7 AT 237 Na 146 K 4,43 Cl 104 TP 6,4 Glob 2,1 AST 24 ALT 21 Alb 4,3 BUN 14 Creat 1 5/5/2014 AL 8,85 Hgb 12,5 HCT 35,3 AT 230 Na 147 K 3,84 Cl 105 BUN 12 Creat 0,94 GOT 22 GPT 22 2/5/14 Hb 13 At 227 Al 9,92 Na 147 K 4,6 Cl 105 Mg 2,04 Alb 4,53 Ca 2,2
M A S A L A H - Luka bakar ec listrik 1%
Balance cairan : CM : cc/24 jam CK : cc/24 jam IWL cc/24jam BC : cc Diuresis : cc/kgBB/jam UOP 2 jam terakhir: cc
Plan : Awasi KU / VS Diet TKTP IVFD RL : 1000 cc/24jam Inj Cefotaxime 1gr/12 jam Inj Ranitidin 50mg/12 jam Inj Ketorolac 30mg/8 jam
FOLLOW UP PASIEN DI BURN UNIT 1. Identitas : Surono, L, 61 th, 1618131 , BB 70 kg TB 170 cm 2. Diagnosis : Combustio gr II 44 % e.c. Api H3 3. Tanggal :11 Mei 2014 4. Harike : 4 O B Y E K T I F
Tgl 11 Mei 2014 05.00 S : Nyeri(+), demam (-) O : KU : Sedang , CM Vital sign : TD: mmhg N : x/menit R : x/menit T : 0 C
Assesment : Combutio grade II 44 % ec Api H3 TBSA: 1,8 IWL = (25+%LB)xTBSAx24 = (25+ 44)x1,8 x24 = 1656 cc/24 jam
Kebutuhan cairan =(1500x1,8)+ IWL = 2700+ 1656 = 4356 cc/24 jam Oral 1000 cc IVFD 3356 cc = 139,8 cc/jam
Kebutuhan protein = 2 g/kgBB / 24 jam = 140 gram P E R K E M B A N G A N
10/5/14 AL 3 HGB 11 HCT 35 AT 45 Na 130 K 4 Cl 103 Alb 1,46 BUN 50 Cre 1,95
7/5/14 AL 16,78 HGB 18 HCT 50,5 AT 95 Na 140 K 3,51 Cl 103 Urine Rutin pH 5,5 Uro Normal Glu Pro Bil Blood +- Ket +- Nitrit Leukosit Warna Jernih
M A S A L A H - Luka bakar ec Api 44 %
Balance cairan : CM : cc/24 jam CK : cc/24 jam IWL cc/24jam BC : cc Diuresis : cc/kgBB/jam UOP 2 jam terakhir: cc
Plan : Awasi KU / VS IVFD HAES : 52,6 cc/jam Inj Ceftriaxon 1gr/12 jam Inj Ranitidin 50mg/12 jam Inj Ketorolac 30mg/8 jam Vit C 100 mg/12 jam Inpepsa syrup Cth I/8 jam Balance cairan/jam Oral : 680 cc