FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
HariKe-

: Ngatmini, P, 45 thn, 1736977, 60kg

: Vulnus Granulosum 4% TBSA ec Combustio post STSG H+34 post release
kontraktur, STSG, FTSG H-2
: 27 September 2015
: 58

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 27 September 2015

(05.00)
S :Demam (-), kejang (-),
nyeri (+) berkurang, VAS =
2
O : KUsedang, CM

26.9.2015
Hb 10,3
AL 8,4
HCT 29,9
Alb 3,03
GDS 231
Na 135
Cl 103

Penyembuhan luka

Vital
BP
HR
RR
T
MAP

Sign :
:120/70mmHg
:84x/mnt
:18x/mnt
:36,5C
: 87

Assessment
- Vulnus Granulosum 4%
TBSA ec Combustio
- Post debridement + STSG
(6/8/2015)
- Post release kontraktur +
STSG +FTSG (25/9/2015)
IWL
= (25+5%)x1.58x24jam
= 47.4x24
= 1138 cc
Kebutuhan Cairan
= (1500xTBSA)+IWL
=(1500x1,58) + 1138 cc
= 3508 cc/24 jam
Kebutuhan Kalori
=(25xBB)+(40x%LB)
=(25x60)+(40x5)
=1700 kkal/24jam

24.9.2015
Hb 11.3
AL 7.31
HCT 33
APTT 25.4
Alb 3,54
Crea 0.49
Na 137
Cl 104
18.9.2015
Alb 3,8
OT 18
PT 29
BUN 13,5
Cr 0,64
Na 136
K 3,8
Cl 101
10.9.2015
Alb 3,71
BUN 14,2
Creat 0,59
Na 138
K 4,1
Cl 105
GDS 132
SGOT 20
SGPT 37

AE 3.49
AT 385

K 3.6

AE 3.87
AT 406
PPT 13.8
INR 1.0
BUN 11.6
GDS 171
K 3.9

AL 6,47
AE 3,77
Hb 11
Hct 32,2
AT 443

AL 8,08
AE 3,83
Hb 11,1
HMT 32,6
AT 412

31.8.2015
Alb 3,78
AL 5,7 Hb 11,0
Hct 32,6 AT 498

Balance Cairan :
CM
:
3100cc/24
jam
CK
:
1910cc/24
jam
IWL
:
1.137cc/24
jam
BC
: 273cc/24 jam
BC kumulatif : +2663cc
Diuresis: 2,1cc/kgBB/jam
UO :1008 cc/8jam terakhir
Plan
Awasi KU/VS/BC
Inj. Ceftriaxon 1g/12jam
Inj. Ketorolac 30mg/8jam
Inj. Ranitidin 50mg/12jam
Phenytoin 200mg/12 jam
Vit B complex 1 tab/ 12
jam
Asam folat 1 mg/ 12 jam

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

Sunardi, L, 56 thn, 1736605, 60 kg

Combustio gr II-III25% tereduksi 20 % sisa 5% ec Api Bensin
27 September 2015
60

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 27 September 2015

(05.00)
S : Demam (-), nyeri
minimal, gatal di bagian
dada dan perut berkurang
VAS = 2
O : KUsedang, CM

10.09.2015
Alb 4,06
BUN 12,1
Creat 0,78
SGOT 23
SGPT 16
Na 139
K 4,23
Cl 97,1

Penyembuhan luka

Vital
BP
HR
RR
T
MAP

Sign :
: 124/80mmHg
:78x/mnt
: 18x/mnt
: 37C
: 94

3.09.2015
AL 9,07
AE 5,84
Hct 43,1
AT 192

AL 10,39
AE 4,25
Hb 11,9
HMT 36,4
AT 553

Hb 14,8
AL 9,07

Assessment
- Combustio
gr
II-III25% 31.08.2015
tereduksi 20 % sisa 5% AL 9,7
ec Api Bensin
BUN 5,8
AE 3,3
Creat 0,7
Hb 9,6
Na 133Hct 29,1
IWL
K 4,4
AT 581
= (25+%LB)xTBSAx24
Cl 97
= (25+5)x1,62x24
= 1166cc/24 jam
30.08.2015
Alb 3,33
Kebutuhan Cairan
Na 133
= (1500xTBSA)+IWL
K 4,8
= 2430 cc + 1166
Cl 95
= 3596 cc/24 jam
Kebutuhan Kalori
=(25xBB)+(40x%LB)
=(25x60)+(40x5)
=1700 kkal

Balance Cairan :
CM
:2300 cc/24 jam
CK
: 1300 cc/24
jam
IWL
: 750cc/24 jam
BC
: 250cc/24 jam
BC kumulatif :+ 3.830 cc
Diuresis: 0,9 cc/kgBB/jam
UO
: 432 cc/8jam terakhir
Plan
Awasi KU/VS/BC
Cefadroxyl 500mg/ 12
jam
As. Mefenamat 500 mg/ 8
jam
Ranitidine 150 mg/ 12
jam
Vit. B Complex
1tab/12jam

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal
Hari Ke-

:
:
:
:

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

Combustio grade II 10%, grade III 15%
27 September 2015
25

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 27 September 2015

(05.00)
S : Nyeri (-), demam (+)
sudah mulai turun, diare (-),
muntah(-)

26.9.2015
Alb 2,6
Ca 1,96
Al 18,3
Hb 10,6
GDS 102
Hct 31,6
Na 132
At 415
K 3,9
Cl 102

Nyeri
Anemia
Hipoalbuminemia
Penyembuhan luka

Vital sIgn
O : KU sedang, cm
BP
: 110/70mmHg
HR
: 125x/mnt
RR
: 21x/mnt
T
:37,40C
MAP
: 84

25.9.2015
Alb 2,52
BUN 9,5
Cre 0,28
GDS 91
Assessment
Na 130,6
-Combustio grade II 10%, grade K 4,97
III 15% ec. bara api
Cl 96
-Anemia
-Syok septik

TBSA
= V21x125/3600 = 0,85
IWL
= (25+%LB)xTBSAx24
= (25+25)x0,85x24
= 1020
Kebutuhan cairan
= (1500xTBSA)+IWL
=(1500x0,85)+1020
= 2295cc/24jam
= 96 cc/jam
Kebutuhan kalori
=(25xBB)+(40x%LB)
=(25x21)+(40x25)
=525+1000
=1525 kkal/24jam

Ca 1,96
Al 27,99
Hb 7,2
Hct 22,2
At 423

22.9.2015
Alb 3,07
PPT
19,5(14,1)
SGOT 17
APTT
30,8(32,2)
SGPT 27
Fibrinogen
259
AL 43,34
D-dimer
2840
Hb
10,8
Procalsitonin 331
Hct 31,4
GDS 116
Na 133
K 6,4
Cl 101
21.9.2015
Alb 3,31
SGOT 20.0
SGPT 33,0
AL 24,65
HB 11,2
HMT 33,8
Na 134

Balance Cairan :
CM
: 1819cc/24 jam
CK
: 1600 cc/24 jam
IWL
:1.020cc/ 24jam
BC
:- 801 cc/24 jam
BC kumulatif :-8933cc
Diuresis: 3 cc/kgBB/jam
UO:504 cc/8jam terakhir
Plan
Awasi KU/VS/BC
Inj. Imipenem 50mg/6jam
Inj. Mikamin 2mg/kgbb
Inj. Fentanyl
1mcg/kgBB/jam
Inj. Paracetamol 300 mg/ 6
jam
RF 2 ml/jam
AA 10% 9ml/jam
Oralit 100ml/tiap BAB
Chloramphenicol zalf
2ddue
Propanolol 4,5g/8jam
Zinc 20mg/24jam
Nacl po 500mg/8jam
Vip albumin 3x1

K 4,31
Cl 102

FOLLOW UP PASIEN DI BURN UNIT

Identitas
Diagnosis
Tanggal

: Radiyem, 1742945, 45 tahun, 55 Kg, 155 cm

: Combustio grade II 29% ec Api
: 27 September 2015

Hari Ke-

: 9

OBJEKTIF

PERKEMBANGAN

MASALAH

Tgl 27 September 2015

(05.00)
S : Nyeri (+), demam (-)
O : KU sedang, CM

26.9.2015
Alb 3,11
Al 13,8
Hb 11,3
Hct 3,2
At 372
Na 134
K 4,2
Cl 103

Nyeri
Penyembuhan luka

Vital
BP
HR
RR
T
MAP

Sign :
: 110/60 mmHg
: 102x/mnt
: 27x/mnt
: 37,4C
: 81

Assessment
-Combustio grade II 29% ec Api

TBSA
= V55x155/3600 = 2,53
IWL
= (25+%LB)xTBSAx24
= (25+29)x1,5x24
= 1944/24 jam
= 81 cc/jam
Kebutuhan cairan
= (1500xTBSA) + IWL
= (1500x1,5) + 1944
= 2250 + 1944
= 4194 cc/24 jam
Kebutuhan kalori
=(25xBB)+(40x%LB)
=(25x55)+(40x29)
=1375 + 1160
=2535 kkal/24jam

25.9.2015
Alb 2,82
BUN 11
Crea 0,41
GDS 131
Na 135
K 3,8
Cl 102

Al 16,09
Hb 10,6
Hct 32,1
At 332

22.9.2015
Alb 2,43Cl 98
BUN 10,9
13,9
Creat 0,64Hb 11,9
GDS 158
4,03
Na 131Hmt 36
K 4,4AT 467
20.9.2015
Alb 2,59
134,4
SGOT 19
3,86
SGPT 25
102
BUN 6,10
13,95
Creat 0,57
4,2
GDS 164
13,1

Balance Cairan :
CM
: 3.960 cc/24
jam
CK
: 2.920 cc/24
jam
IWL
: 1215 cc/ 24
jam
BC
:-175 cc/24 jam
BC kumulatif : -90cc
Diuresis: 2,2 cc/kgBB/jam
UO:960cc/ 8jam terakhir

Plan
Awasi KU/VS/BC
Inj. Fentanyl 1
mcg/kgBB/jam
Inj. Ketorolac 30 mg/8 jam
AL
Inj. Vit C 1amp/ 12 jam
Inj Ranitidine 30 mg/12
jam
AE
Inj. Ceftazidin 1gr/12jam

Na
K
Cl
AL
AE
Hb
HM

T 38
AT
410