Izin melaporkan hasil follow up pasien di ICU hari Senin 08/05/2023 Jam 19.00 WIT
Diagnosa :
- Post SCTP + Tubektomi
- Post Syok Hemoragik
SUBYEKTIF:
*S : Kesadaran baik, lemas (+), pucat (+)
Riwayat penyakit: pasien Post operasi SCTP + Tubektomi dengan syok hemoragik intra
operasi.
OBYEKTIF:
*B1: Airway clear, simetris, rhonki -/-, wheezing -/- RR: 24 x/menit, SpO2 97%
*B2 : TD : 112/56 mmHg, MAP : 75 mmHg, HR : 63x/menit regular kuat angkat , CRT: <
3 detik.
*B3: GCS (E4M6V5) = 15, CA -/- pupil : bulat, isokor, diameter 2,5 mm/2,5 mm, RC:
+/+, S: 36,6°C, RASS : 0 (alert&calm)
*B4 : urin berwarna kuning kemerahan
*B5: tampak datar, peristaltik usus: 8x/menit (normal)
*B6: Edema Tungkai (-/-) , fraktur (-/-)
PEMERIKSAAN PENUNJANG
1. CBC (07/05/2023)
-WBC : 9,5 x 10^3/ul 7
-RBC : 4,04 x 10^6/ul
-HGB : 11,9 g/dl
-HCT : 33,8%
-PLT : 256 x 10^3/dl
Tatalaksana :
F : Puasa 6 jam Post op -> diet lunak TKTP
A : Paracetamol 1 gr/8jam/IV & Tramadol 300 mg -> 2 cc/jam/sp/iv
S : -
T : -
H : Head up 30'
U: Lansoprazole 3 mg/24 jam/IV
G : Target GDS 140-180 mg/dl
S : O2 Nasal Kanul 3 L/menit
D :
- Ceftraxone 2 gr / 24 jam/iv
- Asam Tranexamat 500 mg/8 jam/iv
- IVFD RL 1000 cc + D5% 500cc/24 jam/iv