2.13 Laporan follow-up pasien Sdr.Amn TGL SUBJECTIVE 22012013 OBJECTIVE 1. Airway+cervical control : airway terintubasi 2.

Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 15x/menit dengan ventilator 3. Circulation+bleeding control : TD : 101/63 mmHg N: 58x/menit Akral : hangat kering merah CRT<2 SpO2 :100% 4. Disability : GCS : 2T5 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure T :38 C 1. Airway+cervical control : airway terintubasi 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 15x/menit dengan ventilator, nafas spontan jam 19.00 wib RR : 16x/menit. 3. Circulation+bleeding control : TD : 117/71 mmHg N: 79x/menit Akral : hangat kering merah CRT<2 SpO2 :98% 4. Disability : GCS : 2T5 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm ASSESMENT Post Kraniotomi evakuasi HSD + dekompresi hari ke 0 PLANNING - Infus Ringer asetat 1500cc/24 jam - Infus Manitol 6x100cc - Injeksi Ceftriaxon 2x1 g - Injeksi Fenitoin 3x100 mg - Injeksi Citicoline 3x250 mg - Injeksi Piracetam 4x3 g - Injeksi metamizole 3x50 mg

23012013

Post Kraniotomi evakuasi HSD + dekompresi hari ke-1

Infus Ringer asetat 1500cc/24 jam Infus Manitol 6x100cc Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi metamizole 3x50 mg

5. Exposure : T :38 C 24012013 1. Airway+cervical control : airway terintubasi 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 18x/menit dengan ventilator 3. Circulation+bleeding control : TD : 143/90 mmHg N: 105x/menit Akral : hangat kering merah CRT<2 SpO2 : 98% 4. Disability : GCS : 2T5 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure : T : 37.5 C 1. Airway+cervical control : airway clear, snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 19x/menit dengan O2 masker 5 lpm 3. Circulation+bleeding control : TD : 126/85 mmHg N: 107x/menit Akral : hangat kering merah CRT<2 SpO2 :99% 4. Disability : GCS : 356 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm Post Kraniotomi evakuasi HSD + dekompresi hari ke-2 Infus Ringer asetat 1500cc/24 jam Infus Manitol 6x100cc Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi metamizole 3x50 mg

25012013

Post Kraniotomi evakuasi HSD + dekompresi hari ke-3

Infus Ringer asetat 1500cc/24 jam InfusManitol 6x100cc Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi metamizole 3x50 mg Acc pindah ruangan (Shofa 2.1)

5. Exposure T :37 C 26Panas (+) 012013 1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 22x/menit dengan O2 nasal canul 3 lpm 3. Circulation+bleeding control : TD : 147/85 mmHg N: 116x/menit Akral : hangat kering merah CRT<2 SpO2 :99% 4. Disability : GCS : 456 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure : T :37 C Post Kraniotomi evakuasi HSD + dekompresi hari ke-4 Infus Futrolit 1500cc/24 jam Infus Manitol Tappering off Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet MSS Aff drain

27Panas 01Sakit 2013 (+)

(+), 1. Airway+cervical kepala control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 22x/menit dengan O2 nasal canul 3 lpm 3. Circulation+bleeding control : TD : 129/56 mmHg N: 80x/menit Akral : hangat kering merah CRT<2 SpO2 :98% 4. Disability : GCS : 456 Hemiparesis Sinistra

Post Kraniotomi evakuasi HSD + dekompresi hari ke-5

Infus Ringer laktat+ Futrolit 1500cc/24 jam Infus Manitol Tappering off Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet MSS

RC +/+ PBI 3mm/3mm 5.Exposure T :38,5 C 28Panas (+) 012013 1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 20x/menit dengan O2 nasal canul 4 lpm 3. Circulation+bleeding control : TD : 138/75 mmHg N: 103x/menit Akral : hangat kering merah CRT<2 SpO2 :98% 4. Disability : GCS : 456 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure : T :37,8 C Post Kraniotomi evakuasi HSD + dekompresi hari ke-6 Infus Futrolit 1500cc/24 jam Infus Manitol Tappering off Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet bebas Pro Konsul Spesialis Rehab Medik

29Sakit kepala 1. Airway+cervical 01(+), panas(+) control : 2013 airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 20x/menit 3. Circulation+bleeding control : TD : 137/80 mmHg N: 96x/menit Akral : hangat kering merah CRT<2 SpO2 : 99% 4. Disability : GCS : 456 Hemiparesis Sinistra

Post Kraniotomi evakuasi HSD + dekompresi hari ke-7

Infus Futrolit 1500cc/24 jam Infus Manitol di Stop Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet bebas Pro Konsul Spesialis Rehab Medik

RC +/+ PBI 3mm/3mm 5. Exposure T :37,2 C

30Keluhan (-) 012013

1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 20x/menit dengan O2 nasal canul 3 lpm. 3. Circulation+bleeding control : TD : 137/75 mmHg N: 98x/menit Akral : hangat kering merah CRT<2 SpO2 :98% 4. Disability : GCS : 456 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure T :36,5 C

Post Kraniotomi evakuasi HSD + dekompresi hari ke-8

Infus Futrolit 1500cc/24 jam Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet bebas Mobilisasi Duduk

31Sakit 01(+) 2013

kepala 1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 26x/menit 3. Circulation+bleeding control : TD : 130/79 mmHg N: 95x/menit Akral : hangat kering merah CRT<2 SpO2 : 99% 4. Disability : GCS : 456

Post Kraniotomi evakuasi HSD + dekompresi hari ke-9

Infus Futrolit 1500cc/24 jam+extra ringer asetat 500cc Injeksi Ceftriaxon 2x1 g Injeksi Fenitoin 3x100 mg Injeksi Citicoline 3x250 mg Injeksi Piracetam 4x3 g Injeksi Paracetamol 3x1g Diet bebas

Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure T :36,5 C 01/02 Keluhan (-) /13 1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 24x/menit 3. Circulation+bleeding control : TD : 137/82 mmHg N: 111x/menit Akral : hangat kering merah CRT<2 SpO2 :99% 4. Disability : GCS : 456 Hemiparesis Sinistra RC +/+ PBI 3mm/3mm 5. Exposure T :37,1 C 1. Airway+cervical control : airway clear (+), snoring(-), gargling(-) 2. Breathing : I : Pergerakan dada simetris(+) A : Ves +/+, Rh-/-, Wh-/P: Sonor/sonor RR: 22x/menit 3. Circulation+bleeding control : TD : 120/66 mmHg N: 80x/menit Akral : hangat kering merah CRT<2 SpO2 :98% 4. Disability : GCS : 456 Hemiparesis Sinistra Post Kraniotomi evakuasi HSD + dekompresi hari ke-10 Aff Infus Obat peroral : p.o Piracetam 3x1 p.o Citicoline 3x1 p.o Methylphenidate 3x1 Diet bebas mobilisasi duduk

02/02 Keluhan (-) /13

Post Kraniotomi evakuasi HSD + dekompresi hari ke-11

Acc KRS Pemberian peroral : p.o Piracetam 3x1 p.o Citicoline 3x1 p.o Methylphenidate 3x1 Pro Kontrol ke Poli Bedah saraf tanggal 7 Februari 2013

RC +/+ PBI 3mm/3mm 5.Exposure T :36.8 C