FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

Asep Sulistyo, L, 17 thn, 1744725

Combustio gr II 5% ec listrik
6 November 2015
34

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 6 November 2015

(05.00)
S : Demam (-), nyeri(+)
O: KU sedang, CM

2.11.15
Alb 3,32
SGPT 12
Cr 0,58
135
K 3,80
12,56
Eri 3,69
31,5
AT 728

Nyeri
Penyembuhan luka

Vital
BP
HR
RR
T
MAP

Sign :
: 110/80mmHg
: 92 x/mnt
: 20 x/mnt
: 37,3C
: 90

Assessment
- Combustio gr II 5% ec listrik
IWL
= (25+%LB)xTBSAx24
= (25+5)x1,5x24
= 1080 cc/24 jam
KebutuhanCairan
= (1500xTBSA) + IWL
= (1500x1,5) + 1080 cc
= 3330 cc/24 jam

SGOT 13
GDS 76

Na

Cl 101

AL

Hb 10,4 Hct

26.10.15
Alb 3,34 Hb 10,9 AE
3,67
HT 32,3 AL 9,73 AT
774
22.10.15
Alb 3,05 Hb 11,5
AL 16,14 AT 644
Na 134
K 5,2
Cl 102
GDS 85
BUN 13,7 Cr 0,65
20/10/2015
Alb 2,86
AL 12,07
Na 134
Hb 11,6
K 4,8
Hmt 32,6
Cl101
AT 561
18/10/2015
Alb 3,03
Al 16,00
OT/PT 52/67 Hb 12,3
BUN 18,60
Ht 37,6
Cr 0,77
At 597
GDS 130
Na 132,2
K 5,03
Cl 2,17

Balance Cairan :
CM
: 4022 cc/24 jam
CK
: 2700 cc/24
jam
IWL
: 1088 cc/24
jam
BC
: +234 cc/24
jam
OU
: 2,25 cc/kgBB/jam
Plan
Awasi KU/VS/BC
Fosfomycine 1 gr/12 jam
Paracetamol 350 mg /
8jam kp
Vit c 1tab /8 jam

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

Tugiman, 1747039, 31 tahun, 60 kg, 165 cm

Combustio grade II 15% ec listrik
6 November 2015
17

OBJEKTIF

PERKEMBANGAN

Tgl 6 November 2015 5.11.2015

(05.00)
Alb 2,8
Na 144,8
S : Nyeri (+), demam (+)
OT 99
K 3,15
O : KU sedang, CM
PT 80
Cl 106
BUN 18,6
AL 12,9
Vital Sign
Cr 1,11
AE 3,6
BP
: 158/78 mmHg
GDS 69
Hb 10,1
HR
: 110 x/mnt
Hct 29,2
AT 371
RR
: 20 x/mnt
T
: 38,3 0C
4.11.2015
MAP
: 105
Alb 2,17 Hb 10,2
Na 138 At 286
Assessment
K 3,20
Combustio grade II 17% ec Cl 106
Al 11,45
listrik
TBSA
= V60x165/3600 = 1,66
IWL
= (25+%LB)xTBSAx24
= (25+17)x1,66x24
= 1673 cc/24jam
Kebutuhancairan
= (1500xTBSA)+1673
=(1500x1,66)+1673
= 4163 cc/24jam
= 170 cc/jam

2.11.2015
Alb 2,31 SGOT 55 SGPT
54
BUN 32,0 Cr 1,60
Na 139
K 3,00
Cl 107
AL
15,92
Eri 3,70
Hb 10,3
Hct
29,8
AT 158
1.11.2015
Alb 3,08

29.10.2015
Alb 2,21
Hb 11,4
Kebutuhankalori
Hmt 32,6
=(25xBB)+(40x%LB)
AE 3,93
=(25x60)+(40x17)
AL 17,92
=1500 +680
Na 131Cl 104
=2180kkal/24jam
K 3,50
Saturasi tangan kanan/kiri : SGOT 122,0
SGPT 169
Jari 1 97%/97%
GDS97,0
Jari 2 98%/97%
Jari 3 97%/96%
Jari 4 98%/98%
Jari 5 98%/98%

MASALAH
Nyeri
Penyembuhan luka
Hipoalbuminemia
Peningkatan
transaminase
Hipertensi

Balance Cairan :
CM
: 4250 cc/24
jam
CK
: 3600 cc/24
jam
IWL
:
1592
cc/24jam
BC
: -942 cc/24
jam
UO
: 2,5 cc/kgBB/jam
Plan
Awasi KU/VS/BC
Inj. Ranitidine 50 mg/12
jam
Inj. Ketorolac 30
mg/8jam
Inj. SNMC 1amp/12 jam
Inj. Vit C 1 amp/12 jam
Inf. Albumin 20% 100
cc/24 jam
Curcuma 2x1 tab
Sistenol 3x1 tab
Kapsul garam 3x1 cap
Amlodipin 1x10 mg
Captopril 3x25 mg

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis

enzim

: Isfak Arifin Muhammad, 1741153, 9 tahun, 21 kg, 125 cm

: Combustio grade II 17%

Tanggal
Hari Ke-

: 6 November 2015
: 61

OBJEKTIF

PERKEMBANGAN

Tgl 6 November 2015 5.11.2015

(05.00)
Alb 2,76
AL 8,29
S : Nyeri (+), demam (+)
OT 13
AE 2,98
O : KU sedang, CM
PT 7
Hb 8,1
BUN 5,5
Hct 24,5
Vital Sign
Cr 0,2
AT 399
BP
: 120/70 mmHg
CRP 131
HR
: 124 x/mnt
RR
: 24 x/mnt
2.11.2015
T
: 35,8 0C
Alb 2,40 SGOT 12,0 SGPT
MAP
: 87
6
BUN 5,2 Cr 0,19
GDS
85
Assessment
Na 133
K 3,60
Cl
- Combustio grade II 25% ec 104
bara api
Ca 2,0
AL 7,66
AE
3,49
TBSA
Hb 9,8
Hct 29,5
AT
= V21x125/3600 = 0,85
110
IWL
= (25+%LB)xTBSAx24
= (25+25)x0,85x24
= 1020
Kebutuhancairan
= (1500xTBSA)+IWL
=(1500x0,85)+1020
= 2295cc/24jam
= 96 cc/jam
Kebutuhankalori
=(25xBB)+(40x%LB)
=(25x21)+(40x25)
=525+1000
=1525kkal/24jam

30.10.2015
Procalsitonin 11,53
27.10.2015
Alb 3,13
27.10.2015
Alb 3,12
26.10.2015
Alb 2,38
Na 137
K 3,5
Cl107

AL 23,66
Hb 9,8
Hmt 29,3
AT 471

MASALAH
Nyeri
Penyembuhan luka
Hipoalbuminemia
Anemia
Sepsis
Balance Cairan :
CM
: 1800,5 cc/24
jam
CK
: 710 cc/24
jam
IWL
:
972
cc/24jam
BC
: 217,5 cc/24
jam
UO
: 1,4 cc/kgBB/jam
Plan
Awasi KU/VS/BC
Inj. Meropenem750
mg/8jam
Inj. Chloramphenicol
500 mg/6 jam
Inj. Paracetamol 5 ml/
jam drip continue
Inj. Ranitidine 25 mg/ 12
jam
Inj.Vit C 1/2 Amp/24 jam
AA 17 cc/jam
Propanolol 4,5 mg/8 jam
Cetirizine 5 mg/12 jam
Alb 25% 20ml 2 cc/jam

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

: Usi Amri, 1747634, 31 tahun, 60kg

: ODS trauma okuli, combustio gr I 19 % eccairankimia, combustio gr 2
% eccairankimia
: 6 November 2015
: 12

OBJEKTIF

PERKEMBANGAN

Tgl 6 November 2015 5.11.2015

(05.00)
Alb 4,06
S : Nyeri (+), demam (-)
Na 143,6
O : KU sedang, CM
K 4,26
Cl 99
Vital Sign
AL 39,37
BP
: 130/70mmHg
AE 5,22
HR
: 104x/mnt
Hb 15,6
RR
: 20x/mnt
Hct 45,2
T
: 37,4 0C
AT 309
MAP
: 90
2.11.2015
Alb 3,94 SGOT 28 SGPT
Assessment
58
ODS trauma okuli,
BUN 14,0 Cr 0,80
GDS
combustio gr I 19 % ec 174
cairan kimia,
Na 142
K 4,50
Cl 102
combustio gr III 2 % ec AL 29,92
Eri 5,26
Hb
cairan kimia
15,5
Hct 45,1 AT 173
IWL
= (25+%LB)xTBSAx24
= (25+16)x1,587x24
= 1.561

30.10.2015
Alb 3,38
Cr 0,87
Na 134
K 2,9
Kebutuhancairan
Cl 101
= 50 cc/kgbb/hari
Hb 14,9
= 60X60 = 3000cc/24 jam Hmt 43,1
=1000 cc oral
AT 147
= 2000 cc infus /24 jam = AE 4,9
83cc/jam
AL 23,97
GDS 188,0
Kebutuhankalori
=(25xBB)+(40x%LB)
26/10/15
=(25x58)+(40x19)
Alb 4,38 OT 18
=1400+760
PT 20
BUN 9,9
=2160kkal/24jam
Cr 0,79 GDS 123
Na 140
K 4,30
Cl 103
PPT 13(14,8)
INR 0,93
APTT 27,2(28,4)

MASALAH
Nyeri
Penyembuhan luka
Balance Cairan :
CM
: 4000 cc/24
jam
CK
: 2200 cc/24
jam
IWL
:
1561
cc/24jam
BC
:
+239
cc/24jam
UO
: 1,67 cc/kgBB/jam
Plan
Awasi KU/VS/BC
Methilprednisolon 16
mg II-II-0
Cotrimoxazole 960
mg/12 jam
Vit C 1000 mg/12 jam
Oksitetrasiklin ED 1
ODS/8 jam
SA 1 % ED 1 ODS/12
jam
Cendo lyteers 1 tetes/20
menit

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

Kalman Asyam, 1748580, 2tahun, 10 kg

Combustio gr III 30 % ec air panas, Sepsis
6 November 2015
3

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 6 November 2015 3.11.2015

Sepsis
(05.00)
SGOT 39,00 SGPT 30
Anemia
S : rewel
BUN 6,4
Cr 0,46
O : KU sedang, CM
GDS 105
Na 141
K Balance Cairan :
3,8
CM
: 1208,8 cc/24
Vital Sign
Cl 102
AL 9,8
AE jam
BP
:
3,8
CK
: 950 cc/24
HR
: 148 x/mnt
Hb 9,8
Hct 29 jam
RR
: 28 x/mnt
AT293
IWL
:
300
T
: 36,8 0C
cc/24jam
BC
:
-41,2
cc/24jam
Assessment
UO
: 3,96 cc/kgBB/jam
Combustio gr III 30 % ec
air panas,
Plan
Sepsis
Awasi KU/VS/BC
Inj. Meropenem 400
TBSA
mg/8 jam
= 0,43
Inj. Fentanil 0,2 cc/jam
Paracetamol 100mg/8
IWL
jam (Kp)
= (25+%LB)xTBSAx24
Nystatin 5 cc/6 jam
= (25+30)x0,43x24
= 56 cc / jam = 567 / 24
jam
Kebutuhan cairan
= (740 XTBSA) + IWL
= (750 X 0,43) + 567
= 322 + 567
= 890/24jam
= 37 / jam
Kebutuhan kalori
=(25xBB)+(40x%LB)
=(25x10)+(40x30)
= 1450 kkal/24jam

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

Heri Sukasno Warno, 1748257, 48tahun, 60 kg

Combustio gr II 9 % ec listrik, combustio gr III 1 % ec listrik
6 November 2015
6

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 6 November 2015 4.11.2015

Nyeri
(05.00)
Alb 2,48
Na 129,9
Penyembuhan luka
S : Nyeri (+), demam (+)
OT 129
K4
Hipoalbuminemia
O : KU sedang, CM
PT 139
Cl 102
Peningkatan enzim
BUN 13,4
Hct 25,5
transaminase
Vital Sign
Cr 0,83
AT 264
Anemia
BP
: 148/79 mmHg
AL 20,77
HR
: 112 x/mnt
Hb 8,7
Balance Cairan :
RR
: 20 x/mnt
CM
: 6462 cc/24
T
: 38,40C
2.11.2015
jam
MAP
: 102
Alb 2,96
SGOT 248
CK
: 3800 cc/24
SGPT 125
BUN 8,6 Cr jam
0,82
IWL
:
1344
Assessment
GDS 130
Na 135
K cc/24jam
Combustio gr II 9 %, gr III 1 4,40
BC
:
+1318
Cl 102
AL 14,02 Eri cc/24jam
% ec listrik, Post amputasi
4,38
UO
: 2,88 cc/kgBB/jam
below elbow sinistra H1
Hb 12,5
Hct 35,6 AT
134
Plan
TBSA
Awasi KU/VS/BC
= 1,62
Inj. Ceftriaxone 1 gr/12
1.11.2015
IWL
jam
Alb 2,37
= (25+%LB)xTBSAx24
Inf. Metronidazole 500
GDS 230
= (25+10)x1,62x24
mg/8 jam
= 56 cc / jam = 1344 / 24

Inj. Ketorolac 30 mg/ 8

31.10.2015
jam
jam
Alb 2,25 OT 338

Inj. Ranitidine 50 mg/ 8

PT 113
BUN 6,7
Kebutuhancairan
jam
Cr 0,80
GDS 230
= 50 cc/kgbb/hari
Vit. C 1amp/12 jam
K 4,2
= 60X60 = 3000cc/24 jam Na 130
Albumin 100 cc/24jam
Cl 103
HbSAG(-)
=1000 cc oral
Sistenol 1,5 tab/8 jam
= 2000 cc infus /24 jam = AL 13,05 AE 4,98
HB
14,2
Ht
40,6
83cc/jam
AT 132
PPT 17,9 INR 1,37
Kebutuhankalori
Kontrl PPT 15,2 APTT 34,3
= (25xBB)+(40x%LB)
Kontrol APTT 29,8
= (25x60)+(40x10)
= 1900 kkal/24jam
Saturasi tangan kanan :
Jari 1 94%
Jari 2 95%
Jari 3 95%
Jari 4 96%
Jari 5 96%