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3.7 FOLLOW UP SAAT MRS

Tanggal Subyektif, Obyektif, Assesment Terapi dan Planning
Diagnosis
18/9/2014
(09:30 PICU)
S: Menerima pasien dari triage anak

O : SSP : Compos Mentis
- CV: PJB cyanotic ec suspek ToF
dd/ pulmonal stenosis
- Resp: Tachypneu (+), takikardi (-)
retraksi subkostal
Pneumonia Berat
- GIT: diare (-), BU(+) N
- Hematoonkologi (-)
- Infeksi : instabilitas suhu (-)
- Hematologi (-)
A : Pneumonia sangat berat + PJB
sianotik e.c susp TOF dd/ susp
pulmonal stenosis
Tx :
Nutrisi dan cairan adekuat
Support oksigen

Konsul kardio
(echocardiografi) :
Hasil : single atrium, single
small moderate anterior
muscular VSD
Mild PR, Moderate TR
Saran :
Antifailure
- Furosemide 2 x 4 mg
IV
- Spironolacton 2 x 5
mg
- Digoxin 2 x 20 mcg
Monitor CHF, PLT, FTT, IE,
rencana echo 2 bulan lagi
(Desember 2014)
19/9/2014
(10:00 PICU)
S : (-)
Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
Tx :
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
2

muscular VSD
- Mild PR
- Moderate TR
Respirology
- Takipneu, retraksi (+)
- O2 Support
- Pneumonia berat
GIT (-)
GUT (-)
Infeksi (-)
Hematologi (-)
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 115x/menit
R : 38 x/menit
t
ax
: 36,5C
SpO
2
: 95%

A : Pneumonia berat + single atrium
+ Single small moderate anterior
muscular vsd + mild PR+ moderate
TR + Gizi baik
Susu formula
20ml/kg/bb/jam ~
15ml/3jam (4x)
IVFD D5 NS
300ml/hari ~ 12ml/jam
Aminofusin paed 5%
0,5gr/kg/jam ~ 50ml/hari
Ambroxol syrp
0,5mg/kg/x ~
2,5mg(0,8ml/8jam)
Spironolakton 5mg
Digoxin 20mg 2x1 pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Dexamethasone
0,5/kg/jam ~ 0,8mg/jam
Furosemid 4mg/12jam
Monitoring :
Vital Sign
Balance Cairan
Kesadaran
Balance Cairan
CM : 348 ml
CK : 470 ml
IWL : 124,9 ml
BC : -246,9 ml
PU : 3,6 ml/kg/jam
Bkum : -331,9 ml

20/09/14

S : (-)

Tx :
3

(07:00 PICU) Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
muscular VSD
- Mild PR
- Moderate TR
Respirology
- Takipneu, retraksi (+) berkurang
- O2 Support
- Pneumonia berat
GIT (-)
GUT (-)
Infeksi (-)
Hematologi (-)
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 150x/menit
R : 44 x/menit
t
ax
: 36,5C
SpO
2
: 79%

A : Pneumonia berat + single atrium +
Single small moderate anterior
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
ASI on demand min.
60ml@3jam
Ambroxol syrp
0,5mg/kg/x ~
2,5mg(0,8ml/8jam)
Spironolakton
5mg+Digoxin 20mg 2x1
pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Furosemid 4mg/12jam
Monitoring :
Vital Sign
Balance Cairan
Kesadaran
Balance cairan
CM : 240ml+ASI
CK : 480 ml
IWL : 125ml
BC : +235 ml
PU : 4 ml/kg/jam
Bkum : -96,36 ml
4

muscular vsd + mild PR+ moderate TR
+ Gizi baik
21/09/14
(07:00 PICU)
S : (-)
Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
muscular VSD
- Mild PR
- Moderate TR
Respirology
- Takipneu, retraksi (+) berkurang
- O2 Support
- Pneumonia sangat berat
GIT (-)
GUT (-)
Infeksi : Leukositosis & Trombositosis
CRP 199,2 23,1
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 152x/menit
R : 40 x/menit
t
ax
: 36,5C
SpO
2
: 96%

Tx :
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
ASI on demand min.
60ml@3jam
Ambroxol syrp
0,5mg/kg/x ~
2,5mg(0,8ml/8jam)
Spironolakton
5mg+Digoxin 20mg 2x1
pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Furosemid 4mg/12jam
Monitoring :
Vital Sign
Balance Cairan
Kesadaran
Balance cairan
CM : ASI
CK : 580 ml
IWL : 125ml
BC : ASI 455 ml
PU : 3,91 ml/kg/jam
5

A : Pneumonia sangat berat + single
atrium + Single small moderate
anterior muscular vsd + mild PR+
moderate TR + Gizi baik
Bkum : -551,36 ml
22/09/2014
07.00 (PICU)
S : (-)
Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
muscular VSD
- Mild PR
- Moderate TR
Respirology
- Takipneu, retraksi (+) berkurang
- O2 Support
- Pneumonia sangat berat
GIT (-)
GUT (-)
Infeksi : SIRS (+) 1 Leukositosis
CRP 199,2 23,1
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 140x/menit
R : 66 x/menit
Tx :
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
ASI on demand min.
60ml@3jam
Spironolakton
5mg+Digoxin 20mg 2x1
pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Furosemid 4mg/12jam
Monitoring :
Vital Sign
Balance Cairan
Kesadaran
Balance cairan
CM : 240 ml
CK : 170 ml
IWL : 125ml
BC : -55 ml
PU : 1,25 ml/kg/jam
Bkum : -606,92 ml
6

t
ax
: 36,5C
SpO
2
: 92%

A : Pneumonia sangat berat + single
atrium + Single small moderate
anterior muscular vsd + mild PR+
moderate TR + Gizi baik
23/09/2014
07.00 (PICU)
S : (-)
Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
muscular VSD
- Mild PR
- Moderate TR
Respirology
- Distress nafas
- Pneumonia sangat berat
Infeksi: SIRS (+)3 leukositosis
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 150x/menit
R : 50 x/menit
t
ax
: 36,5C
SpO
2
: 84%

Tx :
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
ASI on demand min.
60ml@3jam/NGT
IVFD D5 NS
500ml/hari ~ 18ml/jam
Spironolakton
5mg+Digoxin 20mg 2x1
pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Furosemid 4mg/12jam
Monitoring :
Vital Sign
Balance Cairan
Kesadaran

Balance Cairan
7

A : Pneumonia sangat berat + single
atrium + Single small moderate
anterior muscular vsd + mild PR+
moderate TR + Gizi baik
CM : 492 ml
CK : 356 ml
IWL : 125ml
BC : -11,2 ml
PU : 2,5 ml/kg/jam
Bkum : -595,72 ml

24/09/2014
07.00 (PICU)
S : (-)
Problem list
O: SSP : (-)
Cardiovascular
- Single atrium
- Small moderate anterior
muscular VSD
- Mild PR
- Moderate TR
Respirology
- Distress nafas
- Pneumonia sangat berat
Infeksi: SIRS (+)3 leukositosis
Nutrisi dan metabolik (-)
St. Present
Kesadaran : E3V3M3 (9/9)
N : 142x/menit
R : 60 x/menit
t
ax
: 36,7C
SpO
2
: 89%

Tx :
Kebutuhan carian 500ml/
hari
Kebutuhan kalori
583kkal/hari
Kebutuhan protein 10
gram/ hari
Puasa sementara
IVFD D5 NS
500ml/hari + NaCl 3%
40ml + KCl 5ml + Ca
Gluconas 5ml ~ 21ml/jam
Spironolakton
5mg+Digoxin 20mg 2x1
pulv
Piperacillin tazobactam
50mg/kg/x ~ 250mg/8jam
Furosemid 4mg/12jam
Dopamin 5mcg/kg/menit
~ 0,5ml/jam
Monitoring :
Vital Sign
Balance Cairan
8

A : Pneumonia sangat berat + single
atrium + Single small moderate
anterior muscular vsd + mild PR+
moderate TR + Gizi baik
Kesadaran

Balance Cairan
CM : 408,5 ml
CK : 385 ml
IWL : 125ml
BC : -101,5 ml
PU : 2,95 ml/kg/jam
Bkum : -691,22 ml