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  • Jam TD N R Uri N WS D Keterangan

    Diunggah oleh

    denybudiman04
    27 tayangan6 halaman
    The document records observations of a patient over time, including vital signs, lab results, and notes on physical exams. Key findings include declining blood pressure, pulse increasing to 110, hematocrit dropping to 33%, and worsening blood gas analysis indicating respiratory acidosis. The patient received repeated blood transfusions and fluid resuscitation but their condition deteriorated as shown by increasing ventilator support and transfer to the ICU.

    Deskripsi Asli:

    observasi

    Judul Asli

    Observasi

    Hak Cipta

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    The document records observations of a patient over time, including vital signs, lab results, and notes on physical exams. Key findings include declining blood pressure, pulse increasing to 110, hematocrit dropping to 33%, and worsening blood gas analysis indicating respiratory acidosis. The patient received repeated blood transfusions and fluid resuscitation but their condition deteriorated as shown by increasing ventilator support and transfer to the ICU.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai PPTX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    27 tayangan6 halaman

    Jam TD N R Uri N WS D Keterangan

    Diunggah oleh

    denybudiman04
    The document records observations of a patient over time, including vital signs, lab results, and notes on physical exams. Key findings include declining blood pressure, pulse increasing to 110, hematocrit dropping to 33%, and worsening blood gas analysis indicating respiratory acidosis. The patient received repeated blood transfusions and fluid resuscitation but their condition deteriorated as shown by increasing ventilator support and transfer to the ICU.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai PPTX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 6

    Observasi

    Jam

    TD

    Uri
    n

    WS
    D

    KETERANGAN

    10.00

    100/6
    0

    92

    28

    40
    cc

    mini
    mal

    GCS: 4T
    Thorax: B&G simetris, VBS Ka=Ki
    Abdomen: datar lembut, BU (+) N, DM (-)

    10075

    88

    28

    50

    mini
    mal

    GCS: 4T
    Hb: 6,5 Ht: 20 L:15.800 Tr: 63.000
    Tranfusi PRC

    12.00

    100/7
    0

    84

    24

    45

    min

    AGD
    pH: 7,380 PCO2: 29,0 PO2: 100,0 HCO3:
    17,0 TCO2: 18,0 BE: -6,0 Sat O2: 98,0 %
    Laktat: 2,5

    13.00

    110/7
    0

    82

    24

    40

    Min

    GCS: 4T
    Thorax: B&G simetris, VBS Ka=Ki
    Abdomen: datar lembut, BU (+) N, DM (-)

    14.00

    100/6
    0

    88

    24

    50

    min

    GCS: 4T
    Hb: 6,7 Ht: 20 L:17.200 Tr: 80.000
    Tranfusi PRC

    11.00

    Observasi
    Jam

    TD

    Uri
    n

    WS
    D

    KETERANGAN

    15.00

    100/6
    0

    88

    24

    45
    cc

    mini
    mal

    GCS: 4T
    Thorax: B&G simetris, VBS Ka=Ki
    Abdomen: datar lembut, BU (+) N, DM (-)

    100/7
    0

    88

    28

    50

    Min

    17.00

    100/7
    0

    84

    24

    45

    Min

    GCS: 4T
    Hb: 7,6 Ht: 23 L:19.900 Tr: 59.000
    Tranfusi PRC

    18.00

    100/6
    0

    82

    24

    40

    Min

    GCS: 4T
    Thorax: B&G simetris, VBS Ka=Ki
    Abdomen: datar lembut, BU (+) N, DM (-)
    Pasien naik ke OK

    19.00

    100/6
    0

    88

    24

    50

    min

    GCS 2T
    Thorax: B&G simetris, VBS Ka=Ki
    Abdomen: datar lembut, BU (+) N, DM (-)
    Rawat NCCU

    16.00

    Observation
    Tim
    e

    BP

    Puls R
    e
    R

    14.3
    0

    90/70

    16.3
    0

    100/7 110
    0

    110 32 36.
    8

    20 36.
    7

    Urin
    e

    Information

    Inisia
    l
    100c
    c,
    yello
    wish

    RR : 32 x/mnt
    Thorax x-ray
    Abdomen : flat, soft, decreased bowel
    sound, tenderness(+), rebound
    tenderness(+). muscular rigidity (+)
    FAST + splenorenal region
    Rehidration 1500 kristaloid 500koloid

    30 cc PT 22.2,INR 1,76, APTT :32.0

    Hb 19,9 Ht :52 WBC 20.700 Platelets


    407.000
    Ureum 99 Cr 1.47 Na 138 ,K: 3,5 ,ALT:32,
    AST :20 Lactate 2,0 , urinalisis : eritrosit
    (-). Lipase 116 amilase 367
    BGA:
    pH 7.382 pCO2 25,0 PO2 76 HCO3 16,0
    TCO2 30.0 BE -8.0 Sat O2 95.0
    a/r thoraks: symetrical chest expansion,
    equal VBS, Ronkhi -/-; wheezing -/-;

    Tim
    e

    BP

    22.0
    0

    115/7
    6

    Observation

    Puls
    e

    R
    R

    78

    20 27,2

    Urin
    e

    Information

    35cc a/r thoraks : Thorax : symmetrical


    chest expansion, equal VBS, ronki
    -/-, wheezing -/WSD: production 10cc, blood,
    undulation (+), air buble (-).
    a/r Abdomen : flat, soft, normal
    bowel sound, tenderness(-),
    rebound tenderness (-). muscular
    rigidity (-)

    00.0
    0

    120/8
    0

    76

    22 36.7

    40
    cc

    Thorax : symmetrical chest


    expansion, equal VBS, ronkhi -/wsd: production 20cc, blood,
    undulation (+), air buble (-).
    Abdomen : flat, soft, normal bowel
    sound, tenderness(-), rebound
    tenderness(-). muscular rigidity (-)

    01.0
    0

    110/8
    0

    77

    20 36.5

    40
    cc

    thorax : symmetrical chest


    expansion, equal VBS, ronkhi -/wsd: production 10cc, blood,
    undulation (+), air buble (-).
    Abdomen : flat, soft, normal bowel

    Observation
    Tim
    e

    BP

    Puls
    e

    R
    R

    Urin
    e

    Information

    02.0
    0

    120/7
    0

    80

    22

    36.6

    30
    cc

    BGA :
    pH
    7.180
    pCO2:
    46,2
    PO2
    62,4,HCO3 16,6
    TCO2 34,5 BE -11,6 SaO2 86,4%

    03.0
    0

    120/8
    0

    78

    21

    36.6

    40
    cc

    BGA :
    pH
    7.167
    pCO2:
    47,9
    PO2
    49,7,HCO3 14,6
    TCO2 30,5 BE -13,6 SaO2 75,1%

    04.0
    0

    110/7
    0

    80

    20

    36.5

    30
    cc

    Thorax
    :
    symmetrical
    chest
    expansion, equal VBS, ronkhi -/-

    05.0
    0

    120/7
    0

    82

    20

    36.6

    20
    cc

    Hb 10,8 Ht:33 L 12.100 Tr 158.000


    BGA :
    pH
    7.167
    pCO2:
    47,9
    PO2
    49,7,HCO3 14,6
    TCO2 30,5 BE -13,6 SaO2 75,1%
    Lactate < 0.8

    06.0
    0

    110/8
    0

    80

    22

    36.7

    40
    cc

    thorax : symmetrical chest


    expansion, equal VBS, ronkhi -/wsd: production -, blood, undulation
    (+), air buble (-).
    Abdomen : flat, soft, normal bowel

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