Morning Report ICU

VVIP. LH/L/51thn
Hari Perawatan ke
Diagnosis : Sepsis ec pneumonia + Pneumonia lobaris + Efusi pleura bilateral + Hipertensi Grade II + CHF IV ec
HHD dd CAD + Anemia renal + CKD 5 on HD ec HNS dd OKD + DM Tipe 2

S = Sesak
O = KU : Sedang , Kes : CM
B1: RR: 34x/m, SpO2: 96%
Sp: Bronkovesikuler, Rh:-/-, Wh:-/-
B2: TD: 145/62mmHg, Nadi: 91x/m, BJ I-I reguler, bising(-),
Sb:39,0oC
B3: GCS E5M6V4, pupil bulat isokor 3mm/3mm
B4: kateter (-)
B5: Abdomen datar, lemas, BU (+) N
B6: akral hangat, edema (-)
Hasil Laboratorium
01 Oktober 2017
Leukosit 8700/uL Ureum Darah 95mg/dL
Eritrosit 2.92 10^6/uL Creatinin Darah 4.6mg/dL
Fosfor 2.5mg/dL
Hemoglobin 8.7g/dL
Magnesium 2.30mg/dL
Hematokrit 25.9% Chlorida DaraH TAP
Trombosit 228 10^3/uL Kalium Darah 3.80mEq/L
MCH 29.8pg Natrium Darah 141mEq/L
Calsium 7.94mg/dL
MCHC 33.6g/dL
MCV 88.7fL
Medikasi
Durante HD cairan masuk
2000cc
• Asam Folat 400mcg/12jam Transfusi 1 PRC
• Atorvastatin 20mg/24jam
• Telmisartan 20mg/24jam
• Bisoprolol 1.25mg/24jam
• Gliseril trinitrat 2.5mg/12jam
• Tromboaspilet 80mg/24jam
• Carvedilol 6.25mg/12jam
• Paracetamol drips 250 cc (extra)
• Levofloxacin 500mg/48jam (H5)
• Ranitidin 50mg/12jam
• Nebulisasi combivent+pulmicort/8jam
 Bed 19. NT/P/73thn
Hari Perawatan ke-25
Diagnosis: Penurunan Kesadaran ec Sepsis + Hipotensi + AKI Superimposed CKD + CHF fc. II ec Suspek
VHD + Hipoalbuminemia + HipoNa+ Hipo K Ringan

• S : kontak (+) Batuk (+)

• O : KU berat, Kesadaran somnolen
B1: RR 19x/m, SpO2 100% dengan NRM 12lpm
Sp: Vesikuler, Rh +/+, Whz -/-
B2: TD 111/63mmHg (dengan Norepinephrine, Vasopresin, dan Dobutamin),
Nadi 112x/m, Isi Cukup, BJ I-II reguler, Sb 36oC
B3: GCS E4M5V2 , pupil bulat isokor
B4: Kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (+)
Analisis Gas Darah
2 Oktober 2017
• pH: 7.327
• pCO2: 45.8
• pO2: 38.5
• SO2: 68.4
• HCT: 27
• Hb: 8.9
• HCO3: 24,2
• BEecf: -2.0
• BEB: -1.1
• PO2/FiO2: 63.2
Medikasi
• KSR 600mg/12jam
• Atorvastatin 20mg/24jam
• Digoxin 0.25mg/24jam
• Dobutamin 5mcg/kgBB/menit
• Levofloxacin 500mg/48jam
• Fluoconazole 400mg/24jam
• Norepenephrine dosis titrasi via sp
• Human albumin 20% iv drips
• Allopurinol 100mg/24jam
• N-asetil sistein 200mg/8jam
• Sucralfat syr 10ml/6jam
 Bed 20. LS/P/66thn
Hari Perawatan ke 3
Diagnosis: Gagal napas on ventilator + penurunan kesadaran ec CVD SH (ICH Temporoparietal Dextra) + SAH Non
Trauma onset H2 + HVH Bilateral + Hipertensi Emergency + Hiperglikemia ec Stress Metabolik

• S: penurunan kesadaran
• O: Ku: Berat, Kesadaran: Koma
B1: RR 12x/m, SpO2 97% dengan Ventilator VC-AC
Sp Vesikuler, Rh -/-, Wh -/-
B2: TD 83/61mmHg (dengan norepinephrine, dobutamin, dan
vasopresin), Nadi 91x/m, BJ I-II reguler, Bising(-), Sb 36.0oC
B3: GCS E1M1Vx, Pupil midriasis bilateral
B4: Kateter(+)
B5: NGT Terpasang, Abdomen datar lemas, BU(+)
B6: Akral hangat
Analisis Gas Darah
2 Oktober 2017
• pH: 7.22
• pCO2: 62.0
• pO2: 70.1
• SO2: 89.2
• HCT: 37
• Hb: 12.2
• HCO3: 25.7
• BEecf: -2.2
• BEB: -2.3
• PO2/FiO2: 87.7
Medikasi
• Sucralfat Syrup 10mL/6jam
• Nimodipin 60mg/6jam bila TD 136/86
• Lactukosa Syrup 7mg/24jam
• Manitol 20% loading 300mL lanjut 150mL/6jam
• Asam Tranexamat 1gr/6jam
• Omeprazole 40mg/12jam
• Paracetamol 1gr/8jam
• Norepinefrin 0,05-1,5mcg/kgBB/jam
• Vasopresin 1.8unit/jam
• Ceftriaxone 1 gr/8jam
 Bed 4. PC/L/17thn. BB: 70kg
Hari Perawatan ke
Diagnosis: Gagal napas terpasang ventilator melalui trakeokanul + penurunan kesadaran ec
edema serebri + Fr. Basis Kranii + Pneumonia HAP + Post hematemesis

• S: penurunan kesadaran
• O: KU sedang, Kesadaran somnolen
B1: RR 14x/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 132/83mmHg, Nadi 69x/m, BJ I-II reguler, bising (-), Sb 35,8oC
B3: GCS E3M5V1, pupil bulat isokor d:3mm/3mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral dingin, edema (-)
Analisis Gas Darah
2 Oktober 2017
• pH 7.540
• pCO2 35.1
• pO2 96.2
• HCO3 33.8
• TCO2 35
• BEecf 11
• BEb 11.1
• pO2/FiO2 594.1
Medikasi
• Zinc 20mg/12jam
• Vit C 200mg/12jam
• Sucralfat syrup 10mL/6jam
• N-asetilsistein 200mg/8jam
• B1B6B12 1 tab/8jam
• Nebulisasi NaCl 0.9%/8jam
• Tygesiklin 50mg/12jam
• Omeprazole 40mg/12jam
• Paracetamol 1gr/8jam
 Bed 21. SL/P/60th
Hari Perawatan ke 12
Diagnosis : post gagal napas terpasang ventilator, post kraniotomi dekompresi ec EDH + ICH + , DM
tipe 2, anemia ec perdarahan akut.

• S: gelisah, bicara kacau

• O: KU berat, Kesadaran delirium
B1: RR 21x/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 131/66 mmHg, Nadi 100x/m, BJ I-II reguler, bising (-), Sb 36.0oC
B3: GCS E4M6V4, pupil bulat isokor d:3mm/3mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
02 Oktober 2017
• pH 7.582
• pCO2 37,4
• pO2 71.8
• SO2 95.7
• Hct 34
• Hb 11.3
• HCO3 25.6
• PO2/F1O2 217.5
Medikasi
• Amlodipin 10 mg/24 jam
• Valsartan 80 mg/24 jam
• Paracetamol 1g g/8 jam
• Sucralfat syr 10 ml(1 gr)/6 jam
• Meropenem 1 gram/8jam
• Ranitidin 50 mg /12 jam
• Novorapid 10 unit/ 6 jam
• Levemir 14 unit pada 22.00
• Nebulisasi NaCl 0,9%/8 jam
• Omeprazole 40 mg/12 jam
• Asam tareksamat 500 mg/8 jam
• KCl drips 100 meq
• Albumin 25%
Lab (2/10/2017)
• Leu 54150
• Hb 8.7
• Trom 535
 Bed 9. MM/P/60 thn
Hari Perawatan Ke 16
Diagnosis : post gagal napas dengan NIV, post penurunan kesadaran ec metabolik dd sepsis, NSTEMI + hipertensi
terkontrol + CHF Fc III + hiperemis , hiperkolestrolemia + hipoalbumin

• S: sesak
• O: KU : berat, Kesadaran CM
B1: RR 18x/m, SpO2 100% tanpa Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 130/70mmHg, Nadi 92x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E4M6V5, pupil isokor 3 mm/3 mm
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Medikasi
• Allopurinol 100 mg/24 jam • Levofloxacin 750 mg/24 jam
• Atorvastatin 20 mg/24 jam • Furosemid 5-20 mg
• Bisoprolol 2,5 mg/24 jam • Miconazole zalf kulit-gosok/12 jam
• Amlodipine 10 mg/24 jam • Nebulisasi NaCl 0,9%/8 jam
• Telmisartan 80 mg/24 jam • Levemir 18 unit
• Gliseril trinitlat 2,5 mg/12 jam • Novorapid 10 unit
• Asam Asetil salisilat 80 mg/24 jam
• Clopidogrel 75 mg/24 jam
• Asam folat 400 mg/12 jam
• KSR 600 mg/12 jam
• Sucralfat 10 ml/6 jam
Analisa Gas Darah
02 Oktober 2017
• pH 7.511 • PO2/F1O2 191,3
• pCO2 32.3
• pO2 114,8
• SO2 97,9
• HCO3 26,1
• Hb 9,3
• Beb 3,8
• HCT 28
 Bed 8. BS/L/50 th
Hari Perawatan ke
Diagnosis : gagal napas terpasang ventilator, penurunan kesadaran ec CVD SH (ICH ganglia basalis), post
hematemesis ec stress ulcer+ DM tipe 2 + hipertensi, epilepsi fokal + penumonia + hiperalbuminemia

• S: penurunan kesadaran
• O: KU berat, Kesadaran coma
B1: RR 18/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh -/-, Whz -/-
B2: TD 115/68mmHg, Nadi 102x/m, BJ I-II reguler, bising (-), Sb 36,7oC
B3: GCS on sedasi, pupil midriasis bilateral d:
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
02 Oktober 2017
• pH 7.508 • PO2/F1O2 429,6
• pCO2 38,1
• pO2 257,7
• HCO3 30,5
• SO2 99,2
• Hb 11,7
• BEecF 7.3
• HCT 35
Laboratorium (2/10/2017)
• Leukosit 13960
• Eritrosit 4.34 10^6
• Hb 12,4
• Hct 35.8
• Trombosit 685.000
• MCH 28.6
• MCHC 34.6
• MCV 82.5
Medikasi
• Sucralfat syr 10 ml/6 jam
• Amlodipin 10 mg/24 jam
• Fenitoin 100 mg/8 jam
• Asam folat 400 mg/12 jam
• B1B6B12 1 tab/8 jam
• Valsartan 80mg/24jam
• Meropenem 1 gr/8 jam
• Omeprazole 40 mg/12 jam
• As. traneksamat 1000 mg/6 jam
• Paracetamol1 gr/8 jam
• Fentanyl 12,5 mg/ jam
• Novorapid 6 unit
• Levemir 12 unit
• GDS 4 porsi
 Bed 7. JK/L/62 th
Perawatan Hari ke 14
Diagnosis : post gagal napas terpasang ventilator, penurunan kesadaran ec CVD SH (ICH pons 15,
hipertensi + hipoalbumin +'hipoNa + hipoCa, post hematemesis ec stress ulcer

• S: Penurunan kesadaran
• O: KU berat, Kesadaran somnolen
B1: RR 15/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh +/+, Whz -/-
B2: TD 136/92mmHg, Nadi 100x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E2M4V1, pupil midriasis bilateral
B4: kateter (+)
B5: NGT terpasang, abdomen datar lemas, BU(+)
B6: akral hangat, edema (-)
Analisa Gas Darah
02 Oktober 2017
• pH 7.523
• pCO2
• pO2 160,9
• SO2 89,5
• Hb 15,1
• Hct 45
• PO2/F1O2 160,9
Medikasi
• N-asetilsistein 200 mg/8 jam
• Amlodipin 10 mg/24 jam
• Valsartan 160 mg/24 jam
• Lactulosa syr 10 ml/24 jam
• Sucralfat 10 ml/6 jam
• Tigesiklin 50 mg/12 jam
• Omeprazole 40 mg/12 jam
• Asam traneksamat 500 mg/8 jam
• Paracetamol 1 gr/8 jam
• Fentanyl 25 mg/jam ivsp
• Midazolam 3-5mg/jam ivsp
Pasbar
 Bed 6. LA/P/51 th
Perawatan Hari ke 1
Diagnosis : gagal napas terpasang ventilator, post total thyroidektomi ai struma multinodosa non
toksik + hemoroid interna grade II

• S: penurunan kesadaran
• O: KU berat, Kesadaran delirium
B1: RR 16/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh -/-, Whz -/-
B2: TD 98/64mmHg, Nadi 56x/m, BJ I-II reguler, bising (-), Sb 36,3oC
B3: GCS on sedasi,
B4: kateter (+)
B5: NGT(-), abdomen datar, BU(-)
B6: akral hangat, edema (-)
Analisa Gas Darah
02 Oktober 2017
• Ph 7.479
• PcO2
• PO2 344,7
• SO2 85,6
• HCT 29
• Hb 9.7
• PO2/FiO2 430,8
Medikasi
• Cefazolin 1g/8jam iv ST(-)
• Ranitidin 50mg/12jam iv
• Midazolam 1,5 m/jam iv sp
• Fentanyl 25-50 mg/jam iv sp
• Suction berkala
• Nebulisasi NaCl 0.9%/8jam
 Bed 3. MJ/L/73 th
Perawatan Hari ke 1
Diagnosis :gagal napas terpasang ventilator, post open torachotomy konversi VATS ai Tumor Paru
kanan lobus superior + atelektasis lobus superior + hipertensi terkontrol

• S: penderita post operasi

• O: KU berat, Kesadaran: somnolen
B1: RR 16/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh -/-, Whz -/-
B2: TD 162/89mmHg, Nadi 97x/m, BJ I-II reguler, bising (-), Sb 36,3oC
B3: GCS E4M6Vx,
B4: kateter (+)
B5: NGT terpasang, abdomen datar, BU(-)
B6: akral hangat, edema (-)
Analisa Gas Darah
02 Oktober 2017
• Ph 7.415
• PcO2
• PO2 155.4
• SO2 83,7
• HCT 23
• Hb 7.7
• PO2/FiO2 259
Medikasi
• Amlodipin 10 mg/24 jam
• Ceftriaxone 1 g/12jam
• Ranitidin 50mg/12jam
• As.Tranexamat 500mg
• Fentanyl 25-50 mcg iv sp drips
• Ketorolac 30 mg/8jam iv
• Nebulisasi ventolin + bisolvon/8
jam
 Bed 10. HY/L/67 th
Perawatan Hari ke 1
Diagnosis : post stabilisasi posterior + dekompresi ec lumbal canal stenosis VL1-2, L3-4, L5

• S: -
• O: KU sedang, Kesadaran CM
B1: RR 14/m, SpO2 99% dengan nasal canul 4L/m, Sp vesikuler, Rh -/-, Whz -/-
B2: TD 119/76mmHg, Nadi 85x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E4M5V6,
B4: kateter (+)
B5: NGT (-), abdomen cembung, BU(+) normal
B6: akral hangat, edema (-)
Analisa Gas Darah
01 Oktober 2017
• Ph 7.462
• PcO2
• PO2 201,3
• SO2 89,1
• HCT 33
• Hb 11,1
• PO2/FiO2 402,6
Medikasi
• Ceftriaxone 1 g/12jam iv
• Omeprazole 40mg/12jam iv
• Methylprednisolon 125mg/12jam
iv
• As. Tranexamat 500mg/8jam iv
• VitK 1 amp/24jam IM
• Paracetamol 500 mg + tramadol 1
amp/8 jam iv
 Bed 24. SL/P/34 th
Perawatan Hari ke 1
Diagnosis : post op dekompresi dan stabilisasi posterior a.i fraktur torakal 12 ec Spondilitis TB

• S: -
• O: KU berat, Kesadaran somnolen
• B1: RR 14/m, SpO2 100% dengan Ventilator, Sp vesikuler, Rh -/+,
Whz -/-
B2: TD 132/88mmHg, Nadi 94x/m, BJ I-II reguler, bising (-), Sb 36,7oC
B3: GCS E4M6Vx,
B4: kateter (+)
B5: NGT (-)
, abdomen cembung, BU(+)
B6: akral hangat, edema (+)
Medikasi
• VitC 200mg (4tab)/12jam • VitK 2 mg/24jam IM
• Fentanyl 25-50 mg IVSP
• Ketorolac 30mg/8jam
• Ondansentron 4 mg/8jam
• Ceftriaxone 1 g/12jam (ST)
• Omeprazole 40mg/12jam
• Methylprednisolon 125mg/8jam
• as.traneksamat 500mg/8jam
 Bed 5. EA/L/57 th
Perawatan Hari ke 1
Diagnosis : penurunan kesadaran ec contusio serebri Regio parietal dextra + pneumosefal + fraktur
segmental + fraktur basis cranii anterior + SAH

• S: penurunan kesadaran
• O: KU berat, Kesadaran sopor
B1: RR 14/m, SpO2 99% dengan nasal canul 4L/m, Sp vesikuler, Rh -/-, Whz -/-
B2: TD 124/86mmHg, Nadi 98x/m, BJ I-II reguler, bising (-), Sb 36oC
B3: GCS E3M5V4,
B4: kateter (+)
B5: NGT (-), abdomen cembung, BU(+) normal
B6: akral hangat, edema (-)
Analisa Gas Darah
03 Oktober 2017
• Ph 7.437
• PcO2 35,8
• PO2 186,6
• SO2
• HCT 29
• Hb 9.6
• Phtc 7428
• PCO2tc 36.8
• PO2tc 189.9
• HCO3 24.4
• TCO2 25.5
• PO2/FiO2 352,1
Laboratorium (1/10/2017)
• Leukosit 25100
• Eritrosit 4.22 10^6
• Hb 12,8
• Hct 35.7
• Trombosit 297.000
• MCH 30.3
• MCHC 35.9
• MCV 84.6
• SGOT/PT 66/28
• Ur/Cr 40/1.4
• GDS 143
• Na 139
• K 3.80
• Osmolaritas 299,75