Ny.

Y/ HP 2
Tgl Objective Assessment Planning
15/7 CNS : DPO Dx : Post sc F:
CVS : TD =76/57-115/85mmHg Eklampsi A : Mo 10 mcg/kg/jm
Support Noradrenalin ARDS
S : Midazolam 2mg/jm
0,05mcg/kg/mt AKI
Hepatitis B T : Heparin 2x5000U

HR : 100-119/mnt, SOFA :12 POD 95

CVP : 9 10,5mmHg APACHE II:26
Resp : SIMV 12 PS10 PEEP 12
FiO2 0,65-0,55PS 12 PEEP6 Hb 11.2/34/29600/137000
FiO2 0,55
Saturasi 98-99%
GIT : distensi (-)
GUT : diuresis 597cc/24jm
( diuresis 0,45 cc/kg/jam )
Balans +1694 cc
H
: Head up 45 derajat
Lab. U : OMZ 2x 20 MG
Gds: 144 Ur/Cr 55/1,73 G : -(GDS 44 )
AGD arteri.
7,2/33/ 102.7/12,4/ Th / Ceftriaxon 1x2gr
13,9/93,5
P/F ratio 158
Na 129/6,4/110/4,18/3,95
Urin: Prot 150/+++
HbsAg positif
Anti HCV neg
Toraks foto: udema paru
tanpa pembesaran jantung
 Ny. Y/ HP 3
Tgl Objective
16/7 CNS : DPO
CVS : TD =115/85-
130/90mmHg
Nor Adrenalin 0,08 mcg/kg/m
HR : 110-134/mnt,
CVP : 6-9mmHg
Resp : PS 12 PEEP6 FiO2 0,55
TV 400ml
Saturasi 98-100%
GIT : distensi (-)
GUT : diuresis 258cc/24jm
( 0,19 cc/kg/jam )
Balans +2217 cc
Assessment Planning
Dx :Post sc F : Nutren 1000kal,Aminofusin
Eklamsi 250cc(KH482, L259, Prt 35)
AKI A : Mo 10 mcg/kg/jm
ARDS
S : Midazolam 5mg/jm
T : Heparin 2x5000U
H
: Head up 45 derajat
Lab. U : OMZ 2x20mg
Hb 9,7/29/24200/128000
Gds: 135 Ur/Cr 25/0,75 G : -(GDS 135)
AGD arteri. ( post SLEDD )
7,4/34/94,9/22,5/-1,2/92,8 Th / Ceftriaxon 1x2gr
Dexametason 4x 1 amp
P/F ratio 172
Konsul IPD unk SLEDD
Na 139/3,5/102/4,37/2,19
SLEDD ,UF 3000 cc
 Ny. Y/ HP 4
Tgl Objective Assessment Planning
17/7 CNS : DPO Dx : Post sc F :Nutren 1000kal,Aminofusin
Eklampsi 500cc (KH682.L 259, P 55)
CVS : TD =100/65- AKI A : Mo 10 mcg/kg/jm
115/85mmHg Hepatitis B
S : Midazolam 5mg/jm
Suhu 37 -38,5C
T:
SOFA :6 POD 18
HR : 110-130/mnt,
APACHE II:18
CVP :9- 11mmHg H
: Head up 45 derajat
Resp : PS12 PEEP 6 FiO2 0,55 Lab. U : OMZ 2x 20mg
TV 350-400ml Hb 7,3/21/18600/52000
Gds: 125 Ur/Cr 28/0,88 G : -(GDS 125)
AGD arteri.
Saturasi 98-99% Th / Ceftriaxon 2x2gr
7,49/33/204,7/25,3/2,1/94,7
GIT : distensi (-) PRC 2 lb
P/F ratio 372
GUT : diuresis 423cc/24jm Ca gluc 1 gr
Na 136/3,4/101/4,24/1,65
( 0,32 cc/kg/jam )
Balans +1732 cc
 Ny. Y/ HP 5
Tgl Objective Assessment Planning
18/7 CNS : DPO Dx : Eklampsi dengan AKI F : Nutren 1000,Aminofusil
L600
250ml(KH482kal,Lmk259,Prot
35
CVS : TD=110/60-116/55mmHg A : Mo 10 mcg/kg/jm
Support S : Midazolam 5mg/jm
Noradrenalin0,02mcg/kg/mt
T:

HR : 115-130/mnt,
CVP : 8mmHg H
: Head up 45 derajat
Resp : PS 10 PEEP 6 FiO2 0,55 Lab. U : OMZ 2x20mg
TV 370-380ml RR 20-24x/men Hb 8,3/24/26100/32000
Gds: 106 Ur/Cr 50/1,15 G : -(GDS 106)
AGD arteri.
Saturasi 98-100% Th / Ceftriaxon 2x2
7,44/38,8/154,9/26,7/2,8/99,
Dexametason 4x 1 amp
GIT : distensi (-) Retensi 140cc 3
Ca gluc 1 gr
GUT : diuresis 2661cc/24jm P/F ratio
SLEDD ,UF 2000 ml
Balans 581 cc Na 136/3,4/101/4,24/1,65
 HP 7 (20 Juli
HP 8 (21 Juli 2010)
2010)
CVS stabil
K.U relatif stabil Suhu 37-39.7C
Urin 2191ml/24 jm Lab:
dgn Lasix 5mg/jm Hb7,8/24/13700/4800
Resp:rencana T- 0
piece, EKSTUBASI PRC 2lb
K+ 3,1koreksi KCl
25mc/3jm
 Ny. Y/ HP 9
Tgl Objective Assessment Planning
22/7 CNS : DPO Dx : Eklampsi dengan AKI F : Diet lunak 1500kal
perbaikan +VAP
CVS : TD=120/65-110/60mmHg A:
Tanpa support S:
T:

HR : 110x/mnt,
CVP : 7-11 mmHg
Resp : Nasal kanul 3lt/mt
RR 24-30 x/mt
Sputum>>,batuk efektif
Saturasi 96-98%
GIT : distensi (-) Diare 2x
GUT : diuresis 561cc/24jm
Balans 1236 cc
Suhu 37,8-39C
H
: Head up 45 derajat
Lab. U : OMZ 2x20mg
Hb 8,0/24/14800/51000
Gds: 76 Ur/Cr 24/0,56 G : -(GDS 106)
AGD arteri.
7,5/25,7/85,2/20,9/-1,7/92,6 Th / Ceftriaxon
2x2Meropenem 3x1gr
P/F ratio 264
Dexametason 2x 10 mg
Na 142/3,7/102/4,12/1,43
Ca gluc 1 gr. MgSO4 1gr
Lasix 10mg/jm5mg/jm
Toraks foto infiltrat lapang
paru kiri
CPIS 8
 HP 10 (23 Juli 2010) HP 11 (24 Juli 2010)
CM,CVS stabil CM,CVS stabil
Resp 3lt/mt,RR 20-30x/mt Resp3lt/mt,RR 20-35x/mt
Suhu 38 C,
Urin1135cc/24jm
Urin 1220/24jm,tanpa Lasix
Balans 1772cc
Meronem :
Lab:Hb
blm dapat(jamkesmas), 7,5/23/20300/103000
sementara
Ca 4,02 Cagluc 1 gr
lanjut Ceftriaxone 2x2gr
Mg 1,59MgSO4 1gr
Lab: Hb
8,2/25/30000/105000 Th/Meropenem3x1 gr
 Ny. Y/ HP 12
Tgl Objective Assessment Planning
25/7 CNS : CM Dx : Eklampsi dgn VAP late F : Nutren 1000,Aminofusil
onset L600
250ml(KH482kal,Lmk259,Prot
35
CVS : TD=130/65-155/90mmHg A : Mo 10 mcg/kg/jm
SOFA :6 POD : 18 S : Midazolam 5mg/jm
T:

HR : 110-120/mnt,
CVP : 6-8mmHg H
: Head up 45 derajat
Resp : nasal kanul 3 lt/mt Lab. U : OMZ 2x20mg
Hb 7,9/24/17900/104000
Gds: 64 G : (GD 64) Gluc 40% 25ml
Na 138/3,2/113/3,99/1,73
Saturasi 97-98% Th / Meropenem 3x1gr
GIT : distensi (-) Dexametason 2x 5 mg
GUT : diuresis 1885cc/24jm Ca gluc 2 gr KCl25mc/24 jm
Balans 2555 cc OBH 3x 1sdm
PRC 1 lb
 HP 13 (26 Juli 2010)
HP 14 (27Juli 2010)
D/P2A0 post SC a.i
CM,CVS: 140/67-
Eklampsi dan VAP 150/85mmHg
(perbaikan)
Suhu 38-39C
CM , CVS : 138/60-
Lab: Hb
150/80mmHg 9,1/27/10200/82000
Suhu 37-37,5 C Ur/Cr 19/0,5
Lab:Hb 9,2/12500/94000 AGD:7,44/23,2/76/-5,4/90,2
Th/meropenem 3x1gr Analisa urin: jamur+
OBH , Dexametason, Th/Meropenem3x1gr
Captopril 3x6,25mg Fluconazol 1x400mg
 Ny. Y/ HP 15
Tgl Objective Assessment Planning
28/7 CNS : CM Dx : P2A0 post SC a.i F : Nutren 1000,Aminofusil
Eklampsi L600
250ml(KH482kal,Lmk259,Prot
35
CVS : TD=130/60-140/90mmHg A : Mo 10 mcg/kg/jm
Pindah S : Midazolam 5mg/jm
ruangan T:

HR : 70-90/mnt,
H
: Head up 45 derajat
Resp : nasal kanul 3 lt/mt Lab. U : OMZ 2x20mg
Hb 8,1/25/7400/65000
Gds: 80 G : (GD 64) Gluc 40% 25ml
Na 138/3/110/4,19/1,70
Saturasi 97-98% Th / Meropenem 3x1gr
GIT : distensi (-) Fluconazol 2x200mg
GUT : diuresis >50cc/jm Captopril 3x6,25mg
Dexametason 1x 5 mg
Ca gluc 2 gr KCl25mc/24 jm
OBH 3x 1sdm