Laporan Jaga ICU

Tanggal 21 April 2023

Tim jaga : OM/RW/WA/LM/ME/HA/EN

BED 1
Ny. Nurheryani/ 71 th/ 01214811/ BPJS/HP 2
DOC dt septic + uroseptic ensefalopati + CAP + AKI perbaikan + DM tipe II + HT on treatment

O/ E4V4M6 TD 160/133 MAP 141 RR 20-22 SaO2 100% on O2 NK 5 lpm T 36.9

Plan:
- Obs KU/Kesadaran/TTV/UOP/BC
- Rontgen BNO 3 posisi (belum transportable)
- Cek GDS/4 jam, cek SE perhari selama drip insulin (gds 02.00 = 137, gds jam 06.00 = 138, on insulin
0.5 iu/jam)
- Evaluasi DR post transfusi (21/4/23)
- K/S urin, K/S darah 21/4/23
- Lacak K/S sputum tgl 26/4/23
-Observasi 2-3 hari, bila tidak ada perbaikan ekskalasi AB (23/4/23)

BED 2
Ny. Sumiati/ 66 th/ 01142992/ BPJS/HP 2
Cerebral infarction + sepsis condition + Ulcus decubitus gr II + CAP non severe + UTI complicata + AKI
st III dd ACKD + hiperglikemi in critically ill + hematokezia + hematuria on spooling DC +
hipernatremia + hipoalbumin

O/ E4V3M4 TD 121/73 MAP 89 RR 16-18 SaO2 100% on O2 NRM 10 lpm T 36.8

Plan
- Obs KU/Kesadaran/TTV/UOP/BC
- Post Tranfusi PRC 2 kolf, Transfusi PRC 1 kolf/hari target Hb >10 (sdh masuk)
- Lapor TS Nefrologi pertimbangan HD ulang  konservatif
- Monitoring UO, BC ,target BC positif
- Lacak hasil KS darah, KS urin, dasar luka tgl 27/4/23
- Lacak hasil MDT, IPF, IRF
- Cek DR, Ur, Cr, SE post HD (21/04/23)  sudah ada
(Hb 10.7 Leu 17.9 HcT 30.9 Tromb 34000 Na/K/Cl 143/3.2/117)
- Pro Colon in loop jika transportable
- USG Urologi 27/04/23
- Algoritma Texas 1, Cek GDS/2 jam. Cek SE/hari selama Drip insulin (21/4/23) (gds 04.00=138, jam
06.00 =110mg/dl on insulin 0.2 iu/jam)

BED 3
Tn. M. Saipullah/24th/01.52.95.39/Lagi pengurusan ke Jasa Raharja/HP 4
Post op kraniektomi dekompresi + evakuasi ai ICH ar frontal
O/ E1VEttM1 TD 138/74 MAP 90 airway on ETT. Ventilator mode VC-SIMV. FiO2 40%. VT 450. Ti
1.4. RR 10. Peep 5. Psupp 3. SpO2 100% MV : 6,78-7,05. Vte 452-495, RR keluaran 16-18, RR
spontan 6-8. T 38.1

Menunggu jawaban dari tim jaga 18/04/2023

Usul:
- Obs KU/Kesadaran/TTV/UOP/BC
- Target UO >0.5cc/kg/jam
- Target BC +-500cc/24 jam
- Target suhu < 37,5 °C ( Kompres dingin, Cold blanked, Kumbah lambung dingin)
- nebul ventolin/8jam
- Target Hb > 10, R/ tranf PRC 1 kolf ( menunggu keluarga)
- usul diet naik entramix 6x150cc
- inf D5 1/4 NS 2000cc/ 24 dilanjutkan, target natrium < 145
- usul koreksi hiperkalemi target > 3,5 dgn usul (4-2.6 × BB x 0,3 + maintenance 1xBB) pemberian
100meq dalam 24 jam --> rencana besok cek SE
- usul manitol turun 2x100

BED 4
Ny. Dine/76th/01.52.97.50/BPJS/HP 3
CAP severe + sepsis dgn DIC + suspITP + iskemik anteroseptal

O/ TD 138/76 MAP 95 RR 20-22 SaO2 100% on O2 7 lpm SM T 36.9

Plan:
- Obs KU/Kesadaran/TTV/UOP/BC
- Lacak hasil KS darah, KS sputum, sputum gram (diambil sample tgl 19/4/23)
- EKG/hari
- Raber TS Paru (+) O2 target SpO2 93-95%
- Weaning oksigen --> spo2 99% on SM 7 lpm (usul blpr) —> tunggu jawaban dr rina SpPD

(Bila pasien Ny dine sudah dipastikan pindah ruangan, rencana masuk pasien Tn. Dalsiri/ 57 tahun/
RMK 01473032/MRS ICU 16-04-23/ MRS Bedah lt.1 18-04-23/Leader TS Bedah Digestif. Raber Divisi
Nefrologi/DoC ec Urosepsis + HT encephalopathy + Susp hypocalcaemia + Post LE + Biopsi +
Ileostomi Day-3 a/i Ileus obstruksi dengan adhesi + Ca buli on kemoterapi + CKD st 5 on HD rutin
(Selasa dan Jumat), terakhir Senin 17/04 + Anemia Moderate (9.2)

BED 5
Tn. Youdy Jonly Rumondor/56th/01.53.00.37/HP 3
Post op craniotomy evakuasi ai ICH

O/ Ramsay 5 on Tiopental 150 mg/jam TD 203/119 MAP 140 N 123 Airway on ETT no. 7,5/22cm,
Breathing on ventilator mode VC-SIMV, FiO2 40% VT 500 I:E 1:2 RR 16 PEEP 5 PSupp 10 -> VTe 550
MV 10,5-11,8 RR total 24 SpO2 100% T 36.9
Plan:
- Obs KU/Kesadaran/TTV/UOP/BC
- SP Nicardipine 2.5mg/jam
- Balanced cairan seimbang
- Nebul salbutamol 1 resp/8 jam (pastikan dinebul)
- Cek Ur/Cr per 48 jam (22/4/23)
- Cek Gds/6 jam (21.00= 155, 04.00= 120mg/dl) insulin stand by

BED 6
Muhammad Hidayatullah/ 01528931/27 tahun/ BPJS/HP 2
DOC dt septic dd metabolic ensefalopathy + septic condition + melena susp non variseal + AKI

O/E4V5M6 TD 112/68 N 82 SaO2 100% on O2 3 lpm NK T 36.9

Plan:
- Obs KU/Kesadaran/TTV/UOP/BC
- GDS/8 jam (23.00 = 126, 06.00 = 104 mg/dl)
- AGD 4 jam post koreksi bicnat (selesai jam 11 mlm) --> pagi ini cek AGD evaluasi
- Hb 4 --> prc ke 2 setelah bicnat (+), rencana tf prc 4 kolf
- Cek Ur/Cr per 48 jam (21/04/23)
- KS darah, KS dasar luka
- Drip NE 0.2, Drip lanso (+) H3
- cek HIV elisa ekspedisi
- Rawat luka/hari
- cek dr, ur./cr, agd (21/4/23) post koreksi

BED 7
Rencana pasien IPD masuk.
Nn. Nabilah/18 tahun/RMK 01528907/ MRS 07/04/2023
Assessment
1. Sepsis condition with HAP
2. Atypical Chest pain dt Lung-related causes HAP?
3. Gagal napas tipe 1 related HAP
4. AKI stg III (improved)
5. Elevated Liver Enzyme dt reactive (improved)

BED 8
Ny. Noranie/74th/01.53.00.34/HP 3
Acute confusional state in geriatric dt infection + syok sepsis + multiple ulkus dekubitus + severe
dehidration with imbalance electrolit + AKI st II dd ACKD + geriatric

O/ E4V5M6 TD 95/71 MAP 76 RR 18-20 SaO2 100% on O2 5 lpm NK T 36.6

Plan
- Obs KU/Kesadaran/TTV/UOP/BC
- NE 0.3
- Transfusi albumin 20% 100 ml (+) 3x
- Transfusi FFP 5 kolf (+)
- Evaluasi Albumin, PT APTT ulang post tranfusi (21/04/23)
- Cek GDP/GD2PP

BED 9
Tn. Taufik akbar/37th/01.52.97.47/HP 3
Doc dt septik dd uremik ensepalopati + syok sepsis + severe CAP + aki st III dd ackd + hipoalbumin

O/ E4V4M6 TD 101/49 MAP 66 SaO2 100% on O2 10 lpm SM RR 24-28 T 36.7

Plan:
- Obs KU/Kesadaran/TTV/UOP/BC
- NE 0.2
- Lacak KS darah (dikirim sampel tgl 19/04/23)
- KS sputum, sputum gram (belum ada sampel)
- USG urologi
- post HD Kamis (20/4/23)
- Cek Albumin, Ur/CR, SE post HD (21/04/23)

BED 10
Tn. Musa/73th/01.52.94.24/HP 7
post op VP shunt ai HC obstruktif ec ICH + IVH dengan AKI st III dd ACKD

O/ E3V3M5 TD 146/95 RR 22-24 SaO2 100% on O2 10 lpm NRM T 36.8

Plan :
- Obs KU/Kesadaran/TTV/UOP/BC

BED 11
An. Alya Sabrina/4th/01.52.45.13/HP 3
Post op re laparatomi eksplorasi + small to small anastomosis ai ileus obstruktif + adhesi

O/ E4V5M6 MAP 79 HR 106 SaO2 99 on O2 5 lpm SM RR 28-30 T 36.8

Plan :
- Obs KU/Kesadaran/TTV/UOP/BC
- Menunggu advice BA