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FOLLOW UP PASIEN DI BURN UNIT

1. Identitas :Yusan, L, 36 thn, 1.67.44.20, ; BB 64kg


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

Assesment :
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 H8

TBSA: 1,5

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

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