Laporan Jaga Bangsal

Sabtu , 11 November 2023

(KAI)
A. Pasien yang dirujuk ke Rumah Sakit lain : 0 Pasien baru : 4
B. Pasien Meninggal : 0
A. Pasien dirawat di NICU ( 3 )
1. Adhisti Maharani / pr/ 3 bulan / Bed 9 / perawatan hari ke-25/ Belum ada perbaikan
S:-
Oh: RSMH Lab 31/10/2023
Hb: 8,9
A : ETT Ht: 24
B : HFO, FiO2 21%, RR 12x/m Leukosit: 3.09
Thrombsit: 216.000
C: HR 131 x/m Ur/Cr : 74/0.59
D: Hipoaktif , pupil isokor 3mm/3mm, Reflex cahaya
(+/+)

Regio Cranium:
I: Luka operasi tertutup kassa kering, rembesan ( - )

Balance cairan
Input : 387.8 cc / 24 jam
Output : 315.9 cc / 24 jam
IWL : 1.3 cc / jam
Total : -12.45 cc/24 jam

A: Post VP Shunt POD 17 (25-10-23) a.i Hydrocephalus communicans

P:
Aminosteril 10% 3.2 cc / jam
IVFD D10 1/5 NS gtt 7.3 cc/jam
BF NGT 8x25 cc
Trigecycline 2.5 mg/ 12 jam
Inj. Metronidazole 42 mg/24 jam IV
Momethason Sue / 8 jam
Glycerin 0.3 cc + Nacl 1.2 cc
Inj. Paracetamol 35 mg/ 8 jam IV
Inj. Penobarbital 5.2 mg /12 jam IV
Micozalf sue / 12 jam
Bac Lofen 0.6 mg/jam PO
2. By. Ny Anita Susanti /Pr /11 hari/Bed 11 / perawatan hari ke 5 / belum ada perbaikan
S:- RSMH Lab 9/11/2023
Hb: 15.5
O: Ht : 39
Leukosit: 13.20
A: Clear Plt: 58
B : Niv 21 % RR 39 x/m SpO2 98%
C: HR 132 x/m
D: Hipoaktif , pupil isokor 3mm/3mm, Reflex Cahaya (+/+)

Regio Abdomen
I: stoma viable, producsi (+) feses
P: Lemah
P: tympani
A : BU (+)

Balance Cairan
Inputs : 321 cc / 24 jam
Output : 184 cc / 24 jam
IWL : 2.1 cc / jam
Total : 137 cc/24 jam

A:
Post Colostomy emergency + Repair Stoma POD 4 (08/11/23) a.i Post colostomy a.i.
MAR tanpa fistula + down syndrome

P:
Cefotaxime 170mg/ 24 jam IV
Gentamycin 9 mg / 8 jam iv
Paracetamol 35mg/ 8 jam iv
3. By Ny Chindy Putri Lestari/Pr /8 hari /Bed 6/ perawatan hari ke 1 /(PASIEN BARU)
S:- RSMH Lab 10/11/23
O: Hb: 13,1
A: Clear Ht : 38
Leukosit : 13,14
B : Niv 21 % RR 67x/m SpO2 97% Plt: 13,1
C: HR 137 x/m
D: Hipoaktif , pupil isokor 3mm/3mm, Reflex Cahaya (+/+)

Regio thorax :
I: luka post op, tertutup verban (+)
P: Lemah
P: tympanic
A : BU (+)

Balance Cairan
Inputs : 331,74 cc / 24 jam
Output : 262,14/ 24 jam
IWL : 5,07 cc / Hour
Total : 63,93 cc/24 jam

A:
Post Thoracotomy esofagio-esofagostomy a.i atresia esofagus tip POD 0 (11/11/23)
P:
Post thoracotomy esofagio-esofagostomy a.i atresia esofagus tip
- Kebutuhan cairan 130 cc/kgbb/hari
- ASI 8x1 cc (continuous feeding) - - > terdapat reflux
- Aminosteril 10% Kec. 2 cc/jam (2.5gr/kgbb)
- D10 138.65cc + D40 23.2cc + NS3% 7.8cc + Ca glu 9.75cc + Ph 1.95cc + KCL 3.9cc
Kec. 7.72 cc/jam (Dx 10 GIR 6.6)
- Ampicilin 2x50 mg iv (6)
- Gentamisin 2x5 mg iv (6)
- Fototerapi 24 jam (premix naik 20% saat Fototerapi)
- Sementara msh TPN krn msh ada reflux saat menggunakan NGT
B. Pasien dirawat di PICU ( 4 )
1. Akhmar Baihaqi /Lk /1 th 5 bulan /1383050/ Perawatan 4 / perbaikan
S/ (-)
O/
RSMH Lab 10/11/23
A: ETT
Hb : 13.0
B: PSIMV+ PEEP 5 FIO2 40 RR: 61x/m SPO2: 100%
HT : 38
C: ABP: 97/56 (74) HR: 102x/m CVP: 9 mmHg
WBC : 15.93
D: GCS E4M6VT, pupil isokor 3mm/3mm, Reflex Cahaya
PLt : 107.000
(+/+)

Regio thorax
I: luka operatsi tertutup kassa steril, rembesan (-), terpasang substernal drain dengan
produksi of 15 cc / jam hemoragik dengan suction cateter -10 mmHg, terpasang pigtail
dengan produksi of 2.2 cc / jam hemorrhagic
P: s sonor hemitoraks A: vesikuler +/+, wh -/-, rh -/-, BJ 1-2 reguler, murmur (-) gallop (-

Balance Cairan
Inputs : 856,32 cc / 24 jam
Output : 968,16/ 24 jam
IWL : 113 cc / Hour
Total : - 224,84 cc/24 jam

A/ Large VSD PMO + Mild TR post VSD Closure POD 2 (9/11/23)

P/
-IVFD Kaen 1B Kec 15cc/jam
-Drip Milrinone 0.375 mcg/kgbb/menit
-Drip Dexmetomidine 0.4 mcg/kgbb/jam
-Drip Morfin 10mcg/kgbb/jam
-Inj. Cefuroxime 400mg/8 jam IV
-Paracetamol 80mg/6 jam IV
2. Fariz Angling Wijaya/Lk/1 tahun 2 bulan / perawatan hari 3/perbaikan
S/ -
Lab RSMH 9/11/23 Jam 15:24
O/
Hb 9.6
A: Clear
Ht 29
B: RR: 31 x/m (hitung manual) SpO2: 98% room air
Leu 20.16
C: NIBP: 101/73 (71) HR: 131 x/m
Plt 357
D: GCS E4M6V5
DC 18/0/5/24/61/5
pH 7.21
BB: 6.3 Kg; TB: 70 cm
PCO2 46.9
PO2 166.5
Regio Thorax
HCO3 19.3
I: luka tertutup opsite kering, rembes (-) terpasang pigtail pericad.

Balance Cairan
Inputs : 611 cc / 24 jam
Output : 390, 6/ 24 jam
IWL : 11,5 cc / Hour
Total : 208, 9 cc/24 jam

A/ Large PDA + Mild TR + Mild PR post Ligasi PDA POD 2 (9/11/23)

P/
-IVFD D5 1/4 NS Kecepatan 18 cc/jam (75% maintenance cairan)
-Drip Morfin 5 mcg/kgbb/jam
-Drip Midazolam 0.5 mcg/kgbb/min
-Inj. Cefuroxime 325mg/8 jam IV
-Paracetamol 130 mg/6 jam IV
-Furosemide 6 mg/12 jam IV
-Captopril 3.125mg/12 jam PO
3. Hinzon Varma / LK / 13 th / Bed 4 / Perawatan hari 20 / tidak ada perbaikan
S: -
O:
A: ETT
B: PSIMV, PEEP 5, FiO2 40 %, RR 21, SpO2 100%
C: Blood pressure: 124/82 mmHg, HR 132 x/m
D: GCS DPO, Isokor +/+ , RC (+/+)

Balance Cairan
Input : 1211 cc/24 jam
RSMH Lab 9/11/2023
Output : 1762 cc/24 jam
Hb: 10.4
IWL : 14,5 cc/jam Ht: 29
Leukosit: 8.08
Total : -551cc/24 jam
Plt: 442.000

Regio Cranium
I: luka operasi kering , darah (-), pus (-)

A.
Post Craniotomy Evacuation POD 30 (13/10 /2023) a.i SDH

P:
IVFD D5 1/2 NS 15 cc/jam
Inj Phenytoin 90mg/12 jam IV
Inj Carbamazepine 300 mg/12 jam IV
Topomex inj 25 mg/12 jam IV
Amikacin Inj 380mg / 24 jam (D-18)
Clobazam 25 mg/24 jam PO
Valproic acid 4 cc/8 jam
Ventolin fls + Nacl 0.9 3 cc per 6 jam Nebu
Erlamicetin zalf / 12 jam
Lactulac 10 cc/ 12 jam PO
Clobazam 2.5 mg/24 jam PO

4 . Edsel Ramadhan / Lk / 17 th / Bed 5 / perawatan hari ke- 12 / tidak ada perbaikan

S :-
O:
A : ETT
B : PSIMV, PEEP 7 , FIO2 50 %, RR : 22 x/m, Spo2 9 9%
C: BP: 1 30/92 mmHg, HR 1 30 x/m
D: GCS DPO, Pupil Isokor 3mm/3mm, LR +/+

Balance Cairan RSMH Lab 8/11/2023

Input : 2456 cc/24 jam Hb : 13,8
Leu : 11.12
Output : 1867 cc/24 jam Plt :151
IWL : 18 cc/hour Ht : 44

Total : + 589 cc/24 jam

A:
Diffuse peritonitis ec perforation of viscous organs (susp. Perforation of the appendix )
+ Sepsis

P:
IVFD Assering XX gtt/m
Inj Metronidazole 350mg / 8 jam iv
Inj Paracetamol 600 mg / 6 jam iv
Inj Meropenem 1.4gr / 8 jam iv
Aminosteride V10% 2.5cc/jam iv
Vitamin K 10 mg/ 24 jam iv
Furosemide 20 mg/12 jam IV
Ventolin 1 fls + Nacl 0.9% 2cc per 8 jam
C. Pasien Dirawat di GICU (8)
1. Rizka Aulia/ P r/ 27 th/ bed 1/ perawatan hari I/ perbaikan
S: -

O:
A : ETT
B : SIMV, PEEP 5, FiO2 50 %, RR 14 x/m, SpO2 100%
C : TD 134/74 mmhg, HR 51 x/m, MAP 94
D : GCS E4M6Vt (10t), pupil isokor 3 mm/3 mm, RC (+/+)

Regio Frontotemporo Parietal Sinistra

I: Luka tertutup kasa, rembes darah (+)

Vitalitas Flap RSMH Lab 10/11/2023

Hb 9,5
Warna : sama dengan donor Ht 30
Suhu : Hangat Plt 197
Wbc 7.16
CRT : < 2 detik GDS 129
Turgor : baik Na/K 141/4.0

Prick Test : tidak dilakukan

Scracth test : Tidak dilakukan
Kesan : Flap Vital

Balance Cairan
Inputs : 2.116 cc / 24 jam
Output : 1.467,6/ 24 jam
IWL : 131,6 cc / Hour
Total : 518 cc/24 jam

A : Post ALT Free Flap + STSG + Craniectomy a/i Dermatofibrosarcoma

protuburans POD 1 (10-11-2023)
P:
- Inj. Ceftriaxone 1 gr/ 12 Jam
- Inj. Metronidazole 500 mg/8 jam
- Inj. Gentamicin 80 mg/12 jam
- Inj. Omeprazole 40 mg/ 24 jam
- Inj. Paracetamol 1 gr/8 jam
- Inj. Precedex 0,3 mcg/kgbb/menit
- Inj. Morphin 10 mcg/kgbb/jam
- Tf Prc 2x200 (2/2)
2. Ahmad Maturidi / Lk / 37 th / 1346965 / Bed 2/ perawatan hari ke-1/ Pasien baru

S: -
O:
A: Clear
B : RR 26 x/m, SpO2 100%
C: BP 154/98 mmHg HR 114 x/m
D : GCS DPO pupil,isokor 3/3 mm, RC +/+

Balance cairan :
Input: 645 cc/ 12 jam Lab, RSMH, 10/11/2023
Hb: 6,7
Output: 263 cc/24 jam Ht: 20
EWL: 21 cc/ hour Wbc: 13,48
Plt: 59.000
Total: + 382 cc/ 12 jam

Region abdomen :
I: luka operasi tertutup kassa kering , rembesan (-) terpasang drain (+), produksi 20 cc
hemorrhagic

A: Respiratory Failure on mechanical ventilation + Post hartmann procedure + Post

partial cystectomy Ali turner buli infiltrasi colon sigmoid POD 0 (11/11/23) + syok
hemoragik gr 4

P:
Inj Ceftriaxone 1 gr/ 12 jam IV
-nj omeprazole 4º mg/24 jam IV
Inj Albumin 20% 24 jam IV
KCL 25 meq dalam 100 cc / habis 4 jam
N acetylsistein 200 mg / 8 jam po
Ventolin 1 flash / 8 jam nebu
Asam tranexamat 500 mg/ 8 jam IV
3. Putut Ali Nurdin / Lk / 28 th / 1351686 / Bed 04/ Perawatan hari 3 / Perbaikan

S: -
O:
A: Clear
B : RR 17 x/m, SpO2 99%
C: BP 121/81 mmHg HR 79 x/m
D : GCS 15 pupil,isokor 3/3 mm, RC +/+

Balance cairan : Lab, RSMH, 10/11/2023

Input: 1320 cc/ 12 jam Hb: 14.4
Ht: 44
Output: 1125 cc/24 jam Wbc: 16.455
EWL: 35 cc/ hour Plt: 203
Total: 195 cc/ 12 jam

Regio Spine :
I: luka operasi tertutup kassa kering , rembesan (-) terpasang drain (+), produksi 20 cc
hemorrhagic

A: Post Laminectomy tumor removal POD 2 (9/11/2023) ai SOL medulla spinalis

P:
IVFD Asering gtt XX/min
Inj. Cefazoline 1 gr / 12 jam
Omeprazole 40 mg / 24 jam
Paracetamol 1000 mg / 8 jam
4. Wartini binti Ajak/Pr/ 51 th/ 0001384786/bed 5/ perawatan hari ke-1/
S: -
O:
A: Clear
B : SIMV+, RR 17 x/m, SpO2 100%
C: BP 136/82 mmHg HR 101 x/m
D : GCS 15 pupil isokor 3/3 mm, RC +/+

Balance cairan :
Input: 1659 cc/ 24 jam Lab, RSMH, 8/11/2023
Output: 765 cc/24 jam Hb: 12,4
Ht: 36
EWL: 35 cc/ hour Wbc: 11.43
Total: 894 cc/ 24 jam Plt: 177

Region spine :
I: luka operasi tertutup kassa steril , rembesan (-) terpasang drain (+), production 20
cc hemorrhagic

A: Post Craniektomi dekompresi ac. ICH temporoparioetal Sinistra + SAH POD

1 (10/11/23)

P:
IVFD Asering gtt XX/min
Inj. Ceftriaxone 1 gr / 12 jam
N acetthyl sistein 200 mg/ 8 jam
Manitol 125 mg/ 6 jam
Omeprazole 40 mg / 24 jam
Paracetamol 1000 mg / 8 jam
5. Marhamah binti Kadiron / Pr /51 th /1384786 /bed 5 / perawatan hari ke-1/
pasien baru
S: -
O:
A: SIMV+, PEEP 5 FiO2 50%
B : RR 12 x/m, SpO2 100%
C: BP 116/76 mmHg HR 105 x/m
D : GCS 15 pupil isokor 3/3 mm, RC +/+

Balance cairan :
Input: 139 cc/ 24 jam Lab, RSMH, 8/11/2023
Hb: 12,4
Output: 750 cc/24 jam Ht: 36
EWL: 20 cc/ jam Wbc: 11.43
Plt: 177
Total: - 611 cc/ 24 jam

Regio Cranium :
I: luka operasi tertutup kassa steril , rembesan (-) terpasang drain (+), production 20
cc hemorrhagic

A: Respiratory Failure mechanical ventilation + post CTR ai SOL intracranial

regio temporal dextra POD 0 (11/11/23)

P:
Inj. Ceftriaxone 1 gr / 12 jam
Omeprazole 40 mg / 24 jam
N acetthyl sistein 200 mg/ 8 jam
Ventolin 1 fl / 8 jam nebu
Dexametason 5 mg / 8 jam IV
Fentanyl 0,1-0,4 mcq
Demetomidine 0,5-0,7 mcg
 Morfin 0,1-03 mcq

6. Ahmad Halimi / Lk /52 Th / 1386158 / Bed 11/ Perawatan 1 /perbaikan

S: -
O:
A: Clear
B : RR 16 x/m, SpO2 98%
C: BP 156/76 mmHg HR 87 x/m
D : GCS 15 pupil isokor 3/3 mm, RC +/+

Balance liquid :
Input: 1632 cc/ 24 jam Lab, RSMH, 8/11/2023
Hb: 10.3
Output: 1287 cc/24 jam Ht: 30
EWL: 30 cc/ jam Wbc: 40.9
Plt: 233
Total: 345 cc/ 24 jam

Region inguinal :
I: Luka operasi tertutup kassa

A: Post Debridement a.i Fournier gangrene bilateral + Abses perianal + CKD on HD +

DM Type II POD 1 (10/11/23)

P:
IVFD Asering gtt XX/min
Inj. Meropenem 500mg / 8 jam
Inj. Metronidazole 500mg / 8 jam
Candesartan 8mg/24 jam
Peinloss 800mg/8 jam
Omeprazole 40mg/24 jam
Asam folat 1mg/8 jam
Amlodipine 10mg/24 jam
7. Junaidi bin Supadi / Lk /51 tahun / 1352557/ Bed 7/ Perawatan 1 /Perbaikan pasien
baru

S: -
O:
A: Clear
B : RR 19 x/m, SpO2 100%
C: BP 121/780 mmHg HR 95 x/m
D : GCS 15 pupil isokor 3/3 mm, RC +/+

Balance Cairan :
Lab, RSMH, 11/11/2023
Input: 1632 cc/ 24 jam Hb:9,1
Ht: 27
Output: 1287 cc/24 jam
Wbc: 12,38
EWL: 30 cc/ jam Plt: 288.000
Total: 345 cc/ 24 jam

Region Abdomen:
I: colostomy (+)

A: Post Colostomy + Biopsi Colorectal ai susp ca colon POD 0 (11/11/23)

P:
IVFD Asering gtt XX/min
Inj. Meropenem 500mg / 8 jam
Omeprazole 40mg/24 jam
Inj Asam Tranexamat 500 mg IV
Omeprazole 40mg/24 jam
8. Konaria binti Majtik/Pr /62 Th/Bed 9 /perawatan hari ke-3 / perbaikan
S: -
O:
A: Clear
B : SIMV+, PEEP 5, Fi02 40%, RR 15x/m, SpO2 100%
C: BP 121/76 mmHg HR 60 x/m
D : GCS DPO, Pupil, isokor, Ukuran 3/3 mm, RC +/+

Balance Cairan :
Input: 730cc/ 12 jam Lab, RSMH, 9/11/2023
Hb: 12,9
Output: 610 cc/24 jam Ht:39
EWL: 35 cc/ hour Wbc: 6,95
Plt:309
Total: 120 cc/ 12 jam

Regio cranium:
I: luka operasi tertutup kassa steril , rembesan (-), terpasang drain, produksi 20 cc,
hemoragik

A: Post Craniektomi dekompresi a.i ICH temporoparioetak Sinistra + SAH POD

1 (10/11/23)

P:
IVFD Asering gtt XX/min
Inj. Ceftriaxone 1 gr / 12 jam
N-acetthyl sistein 200 mg/8 jam
Manitol 125 mg/ 6 jam
Ventolin 1 fls/8jam, Nebul
Vit K / tiap 8 am