PENGELOLAAN KEBUTUHAN

CAIRAN
PADA PASIEN COVID-19
RIRI MARIA, S. Kp. MNAP
Dosen KMB FIK UI

Kolegium Keperawatan Medikal Bedah

OUTLINE

KASUS COVID-19

PATOFISIOLOGI COVID-19

KONSEP TERAPI CAIRAN

PENGELOLAAN KEB. CAIRAN PADA PASIEN

COVID-19
KASUS COVID-19
INDONESIA GLOBAL
5.796.257 362.483
Terkonfirmasi Meninggal

Update: 30 Mei 2020 | Sumber: Covid19.go.id

Total Jumlah Kematian/ 1

No Negara kasus Meninggal penduduk juta penduduk
1 Amerika Serikat 1,675,258 98,889 331,002,651 299
2 Brasil 411,821 25,598 212,559,417 120
3 Rusia 387,623 4,374 145,934,462 30
4 Inggris 269,131 37,837 67,886,011 5557
5 Spanyol 238,278 29,037 46,754,778 621
+557
6 Italia 231,732 33,142 60,461,826 548
+523
7 Jerman 180,458 8,450 83,783,942 101
8 Turki 165,799 4,706 84,339,067 56 +53

9 India 160,979 4,461 1,380,004,385 3

10 Prancis 146,122 28,608 65,273,511 438
31 Indonesia 25,773 1,573 296,603,400 6
Sumber: World Health Organiation (WHO), worldmeters.info (UN Population Division), BPS
 PATOFISIOLOGI COVID-19
TARGET CELL:
TIPE II
PNEUMOCYTE

Hemaglutinin- Sel host receptor: ACE 2

Esterase (HE)
2. Penetrasi
Single stranded RNA
(ssRNA) positif
3. Biosintesis
Membran (M)

Nucleocapsid (N) 1. Binding

4. Maturasi
4. Release
Spike glikoprotein (S)
Small Envelope Protein (E)

(Yuki, Fujiogi & Koutsogiannaki, 2020; Guo, et al., 2020)

COVID
Designed by Avesta Roston Gas Exchange
O www.azuravesto.com
Each sac of air, or alveolus, is
O @azurovesta
wrapped with capillaries where
@ @azuroviz red blood cells release carbon
dioxide (C02) and pick up oxygen

-19
(02 ). Two alveolar cells facilitate
gas exchange; Type I cells are
thin enough that the oxygen
Coronavirus Disease 2019 (COVID-19) is a pandemic passes right through, and Type II
cells secrete surfactant - a
caused by Severe Acute Respiratory Syndrome
Coronavirus 2, also called SARS-CoV-2. Despite the subtsance that lines the alveolus
widespread awareness regarding COVI0-19, many are Normal and prevents it from collapsing.
HOW DOES IT AFFECT YOU?
still unaware about how it affects the human body. gas exchange

-:---- Left Lung

Infected SARS-CoV-2 Structure Viral Infection
-i"-c-�-,--- Trachea
Membrane protein The spike proteins covering the
coronavirus bind ACE2 receptors
Nucleoplasmid primarily on type II alveolar cells.
(enclosed allowing the virus to inject its
RNA) RNA. The RNA "hijacks" the cell,
telling it to assemble many more
Lipid membrane
copies of the virus and release
them into the alveolus. The host
Envelope cell is destroyed in this process
SARS·CoV-2 starts its journey in the nose, protein and the new coronaviruses infect
Spike protein
mouth, or eyes and travels down to the alveoli in neighbouring cells.
the lungs. Alveoli are tiny sacs of air where gas
exchange occurs.

Immune Response
----- Vasodilatlon (increase After infection. Type II cells release inflammatory
permeability Stay signals that recruit macrophages (Immune cells).
) Home
u1,,;,.....:__ Macrophage Macrophages release cytokines that cause
vasodilation, which allows more immune cells to
--��-- Cytokines come to the site of injury and exit the capillary.

lf:i\1::·:
_... Inflammator
_,. y Fluid accumulates inside the alveolus.
signals
------ Reduced surfactant
------- Infected Type ¥#1·· O The fluid dilutes the surfactant which triggers the
onset of alveolar collapse. decreasing gas

iifa:IIIHM
II alveolar cell exchange and increasing the work of breathing.
Reduced
gas 0 Neutrophils are recruited to the site of infection

Severe
exchange
Impaired Gas Exchange
I·• and release Reactive Oxygen Species (ROS)
to destroy infected cells.
Hospitalizatio
When the immune system attacks the
area of infection it also kills healthy
Intensiven Care (ICU) 0 Type I and II cells are destroyed, leading to

ll1j,ujj.
the collapse of the alveolus and causing
alveolar cells. This results in three Acute Respiratory Distress Syndrome

w
things that hinder gas
(ARDS).
exchange: f) If inflammation becomes severe. the protein·
rich fluid can enter the bloodstream and travel
1) Alveolar collapse due to loss of elsewhere in the body, causing Systemic Inflam•
-"--------- Protein and
surfactant from Type II cells matory Response Syndrome (SIRS).
cellular debris
2) Less oxygen enters the blood•
stream due to lack ofType I cells
Greatly
�""-'----- Formation of
scar tissue 3) More fluid enters the alveolus
With proper c:are,
patients may recover at
O SIRS may lead to septic shock and multi-organ
any point during this failure, which can have fatal consequences.
hindered gas process
exchange
 PATOFISIOLOGI COVID-19
Sitokin → permeabilitas PD

Kebocoran cairan plasma

ke interstitial

Pelepasan RNA →
Alveolus merusak Tipe II Memungkinkan Mengganggu
Pneumosit cairan masuk ke pertukaran gas
alveolus

Surfactant Hipokesemia
Edema alveolar
Sitokin:
IL1-β, IL1RA, IL7, IL8, IL9,
Sesak napas
fluid sitokin
IL10, basic FGF2, GCSF, fluid
GMCSF, IFNγ, IP10, MCP1,
MIP1α, MIP1β, PDGFB, Surface
TNFα, and VEGFA tension RR meningkat
fluid fluid
ARDS

Alveolar
collaps

(Yuki, Fujiogi & Koutsogiannaki, 2020; Guo, et al., 2020; Huang et al., 2020)
 PATOFISIOLOGI COVID-19

Neutrofil masuk ke alveolus

Konsolidasi di alveolus

Sekret / dahak

Pertukaran
Batuk gas terganggu

Hipokesemia

Sesak napas

RR meningkat

(Yuki, Fujiogi & Koutsogiannaki, 2020; Guo, et al., 2020; Huang et al., 2020)
 PATOFISIOLOGI COVID-19

Proinflamatory cytokine beredar di

Pembuluh darah Inflamasi sistemik

Sampai di hipotalamus Too much fluid leakage

Stimulus peningkatan suhu tubuh

Volume darah
Sitokin:
IL 1 & IL6
Demam TD
Hipovolemia

Produksi keringat dan evaporasi Perfusi jaringan

Resiko Kekurangan cairan Syok Multiple organ

sepsis failure

(Yuki, Fujiogi & Koutsogiannaki, 2020; Guo, et al., 2020; Huang et al., 2020)
 GEJALA COVID-19

Demam >38C Batuk Nyeri / sakit Sesak napas Lainnya

tenggorokan
Hidung tersumbat
Gejala Ringan Ya Ya Ya - Malaise
Pada anak: batuk
Gejala Sedang Ya Menetap Ya Ya dan takipnea
Pem. Lanjutan:
- SaO2 <90%
- Tes darah
Gejala Berat Menetap Ya Ya Ya (leukopenia,
monist dan
limfosit atipik
meningkat)
Sumber: Gugus Tugas COVID-19. (2020). Pedoman penanganan cepat medis dan kesehatan masyarakat COVID-19 di Indonesia. Jakarta
 KLASIFIKASI COVID-19
Hasil tes COVID: positif
TANPA GEJALA Tidak ditemukan gejala klinis dan Rontgen thorax normal

Infeksi saluran napas akut: demam, lemas, myalgia, sakit

tenggorokan, hidung berlendir, bersin-bersin
GEJALA RINGAN Gejala digestif: mual, muntah, nyeri abdomen, dan diare

Pneumonia dengan tanpa hipoksemia yang jelas

GEJALA SEDANG CT Thorax ada lesi

Hipoksemia (SpO2 < 92%) (Gagal napas), ARDS, syok dan/atau

multiple organ failure (gagal jantung, gagal ginjal akut,
GEJALA BERAT miocardial injury, encelofati)

(Yuki, Fujiogi & Koutsogiannaki, 2020)

 Komposisi Cairan Tubuh Manusia

Cairan itu ... (rata-rata)

50% dari total BB wanita | 60% dari total BB laki-laki

2/3 di Intraseluler & 1/3 di Ekstrasel

KESEIMBANGAN CAIRAN
INTAKE = OUTPUT

(Silverthron, 2010)
Tubuh akan
menjaga
keseimbangan
cairan dengan
berbagai
sistem, dan
yang paling
berperan
adalah ginjal
 Perubahan Keseimbangan Cairan
Kehilangan cairan berkontribusi terhadap perubahan keseimbangan
cairan, mengakibatkan hipovolemia (kekurangan cairan)

Faktor yang menyebabkan kehilangan cairan:

Ill

Urinasi Defekasi Kehilangan Wound Gastric Muntah Bernapas

darah drainage drainage

Sensible Insensible
 Renin-
Angiotensin-
Aldosteron
System
(RAAS)

Sebagai mekanisme
kompensasi
homeostatik

(Silverthron, 2010)
 OEH'YORATION

1
Kompensasi
+ Blood "'Olume/ • Osmolarity - - - - .....
• Blood prosSt.Jr-e

l
Hemoestatik
::AA.CM OVASCUl..AA AENl�ANGIOTENSIN RENAL HYPOTHAL.NJtlC
MCCHANISMS SV'STCM MCOtANISMS M£CHANISMS Hypo.thalamic
oernorecep.�

0
pada
Qlro1 d and oortic bero Atrial \ilOllu ma roceptors;
recep tC>r'8 Q.lro1d ond aortic
Gr•nular 0) • Flew, ot
- maculn denao t;:;::;�;:i
+ GF R bar-orocepto..-a:
�

l
cella
+

Dehidrasi C'-CC
+

J VCMum• H)1)04halamua
Ren In coneef"ved

.
I -���...�----,-I 0r--------....

� =�
! Angfoten8nog.en 1' .,,...,
G
� • Vreal.eao perefareoimn
Sy mpe ----�--.th��s-�- etJc 'r--'-"....:. -------------,---------'
Parasympothetlc
OUl)-ut � �

Heart
E) � LP�C:AENl�G��j·---------------p�oete-rl-o,,·-p-tu to_ry _0·=-- �
01
.,,.,, 11 • osnctarlt_y 1nf1NYt• _

-
Va.socon strlction co..-tex

.., Rote •Fot"ce

l .....
4 Pef"lphef"DI
reai&1:ance OIMel
nephron
�
•Na'""
,eebecwp1l
on

+Cef"dOC •Blood �H.,0 9'H:r0

outpul preseure reebeo..-ption intake
(Silverthron, 2010)
 Tanda dan Gejala Dehidrasi, Kelebihan Cairan,
dan Syok

Dehidrasi Kelebihan cairan Syok (cepat)

- Kehilangan cairan - BB naik - Wajah memerah

- Haus - Keseimbangan cairan positif - Sakit kepala dan pusing
- Iritable, gelisah, kebingungan - Nadi meningkat - Kongesti dada akibat akumulasi
- Turgor kulit berkurang - CVP meningkat cairan
- Mulut kering - Edema perifer - Takikardi
- Keseimbangan cairan negatif - Suara serak - TD menurun
- Dispnea, sianosis, dan batuk - Sinkop
(karena edema paru) - Syok
- Kardiovaskular kolaps

(Gues, 2020)
 Pengkajian Status Cairan

• Pasien dngan hipovolemia ditandai dengan takikardi, hipotensi, SaO2

Mencatat TTV dan NEWS2 rendah, dan oliguria

Monitor intake dan output • Monitor dilakukan selama 24 jam. Semua sumber intake dan output
cairan cairan pasien perlu dicatat.

• Pada orang dewasa, nilai minimum volume urin adalah 0.5mL/kg/jam.

Kaji dan observasi haluaran urin
• Pengkajian urin: volume, bau, dan warna

Mempertimbangkan kehilangan • Rata-rata volume cairan yang hilang adalah 650mL/hari.

cairan yang insesible • RR meningkat mempengaruhi peningkatan kehilangan
cairan

Mengukur CRT • CRT > 2 detik mengindikasikan hipovolemia

• Biochemical marker (urea, kreatinin, laktat, Ht, Hb)

Pemeriksaan lebih lanjut
• Echocardiografy
(Gues, 2020)
Indikator Resusitasi Cairan:
▪ Tekanan darah sistolik <100 mmHg
▪ Nadi >90x/menit
▪ CRT >2 detik
▪ Perifer teraba dingin
▪ RR >20x/menit
▪ NEWS2 >= 5
▪ Passive leg raising → fluid
responsiveness

(NICE 2017 dalam Gues, 2020 )

Hitung Kebutuhan Cairan

Kebutuhan cairan dewasa per 24 jam

30cc/KgBB

Setiap suhu tubuh meningkat 1 C dari keadaan suhu

normal (37,5) → ditambahkan kebutuhan cairan 12 – 15%
dari kebutuhan cairan normal dalam 24jam

Rumus jika terjadi kenaikan suhu, menjadi:

Keb. Carian per 24 jam + [Kenaikan suhu(12-15% x Keb. Cairan per 24 jam)]

Contoh: Suhu tubuh Px. A 39 C, dengan berat badan 50 Kg.

Keb. Cairan normal = 30 x 50 = 1500 mL

Keb. Cairan total = 1500 + [1,5 (12% x 1500)]
= 1500 + 270
= 1770 mL/24 jam
 Jenis-jenis Cairan Intavena

Kristaloid Koloid
Definisi Larutan atau cairan mengandung Larutan atau cairan yang
mengandung garam atau gula dengan berat molekul molekul lebih besar
(molekul tidak rendah. dapat melewati
membran kapiler).
Macam-macamnya
Mostly, berada dalam intravaskular.
NaCl 0,9%, RL, dan dextrose 5% Gelatin, dekstran, dan pati hidroksietil
(HES)
Kelebihan Biaya murah dan sedikit efek samping Hanya butuh sedikit koloid
untuk mengisi cairan
Kelemahan Ketika masuk ke ruang instraseluler,
intravaskular
- Tidak efektif dalam menggantikan
dapat menyebakan edema kehilangan cairan interseluler dan
interstitial
- Peningkatan risiko komplikasi

(Gues, 2020)
 Algorithms for IV fluid therapy in adults
NICE National Institute for
Health and Care Excellence
T Algorithm 1: Assessment

e
r
Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient Is hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg; heart rate
>90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS ;;:5; 45° passive leg raising suggests fluid responsiveness.

r Assess the patient's likely fluid and electrolyte needs

Algorithm 2: Fluid Resuscitation

a
History: previous limited intake, thirst, abnormal losses, comorbidities.
Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension.
Clinical monitoring: NEWS, fluid balance charts, weight.
Initiate treatment Laboratory assessments: FBC, urea, creatinine and electrolytes.

p
Identify cause
of deficit and
respond. Give Ensure nutrition and fluid needs are met Also
a fluid bolus Can the patient meet their fluid and/or electrolyte needs orally or enterally? see Nutrition support in adults (NICE dinical

i
of 500 ml of guideline 32).
crystalloid
(containing
sodium in the
range of Does the patient have complex fluid or
Algorithm 4: Replacement and Redistribution
r
Reassess the patient
130-154 mmoVI)using
over the
lessABCDE
than 15 electrolyte replacement or abnormal
approach
minutes. distribution issues?

I Does the patient still need fluid

resuscitation? Seek expert help If unsure
Look for existing deficits or excesses,
Existing fluid or Ongoing abnormal fluid or Redistribution and other

C
ongoing
electrolyte deficits or electrolyte losses complex issues Check
abnormal losses, abnormal distribution or excesses Check ongoing losses and estimate for:
other Check for: amounts. Check for: gross oedema
complex issues. dehydration vomiting and NG tube loss severe sepsis

a Does the patient have

fluid overload
hyperkalaemia/
hypokalaemia
biliary drainage loss
high/low volume ileal stoma
loss
hypematraemia/
hyponatraemia
renal, liver and/or
signs of shock? Algorithm 3: Routine Maintenance diarrhoea/excess colostomy cardiac impairment.

i
Estimate deficits or loss post-operative fluid
excesses. ongoing blood loss, e.q. retention and
melaena redistribution
Give maintenance IV fluids malnourished and
sweating/fever/dehydration
Normal daily fluid and electrolyte requirements:

r --' l
pancreatic/jejunal refeeding issues
25-30 mVkg'd v.eter fistula/stoma loss Seek expert help if
1 mmoVkg/day sodium, potassium", chloride urinary loss, e.g. post AKI necessary and estimate
>2000 ml L....:.::..J 50-100 g/day glucose (e.g. glucose 5% contains pdyuria. requirements.
5 g/100ml).

a
Seek expert help

---
-g-v_e_n_?.,....,==�
I I

GJ +
Prescribe by adding to or subtracting from routine maintenance, adjusting for all other sources

n
Reassess and monitor the patient of fluid and electrolytes (oral, enteral and drug prescriptions)
Stop IV fluids when no longer needed.
Give a further fluid bolus of 25�00 ml of Nasogastric fluids or enteral feeding are preferable
crystalloid when maintenance needs are more than 3 days.
Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring

'Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids oontaining 20 mmol and 40 mmol of potassium in a 24-hour period).
Potassium should not be added to intravenous fluid bags as this is dangerous.
'Intravenous fluid therapy in adults in hospital', NICE clinical guideline 174 (December 2013. Last update December 2016) © National Institute for Health and Care Excellence 2013. All rights reserved.
GUIDELINES TERAPI CAIRAN PADA PASIEN COVID-19
Surviving Sepsis Campaign
- Mengukur parameter dinamik untuk
menilai fluid responsiveness
(rekomendasi lemah, low quality of
evidence (QE))
- Menggunakan strategi pemberian
cairan konservatif rekomendasi
lemah, very low quality of evidence
(QE))
- Menggunakan kritaloid lebih disukai
daripada koloid (rekomendasi kuat,
moderate quality of evidence (QE))
- Keseimbangan kristaloid lebih
disukai daripada kristaloid tidak
seimbang (rekomendasi lemah,
moderate quality of evidence (QE))
World Health Organiation (WHO)
- Gunakan strategi manajemen cairan konservatif untuk pasien ARDS tanpa
hipoperfusi jaringan
- Dalam resusitasi untuk syok septik (dewasa) →berikan 250-500 mL cairan
kristaloid (bolus cepat dalam 15-30 menit pertama), kaji ulang tanda kelebihan
cairan setelah setiap bolus
- Jika ada tanda-tanda kelebihan cairan, kurangi atau hentikan pemberian cairan
- Pertimbangkan indikasi dinamik volume responsiveness untuk memandu
pemberian volume diluar dari resusitasi awal berdasarkan sumber daya dan
pengalaman. Indikasinya meliputi: passive leg raises, fluid challenges with serial
stroke volume measurements, or variations in systolic pressure, pulse pressure,
inferior vena cava size, or stroke volume in response to changes in intrathoracic
pressure during mechanical ventilation.
- Koloid dikaitkan dengan peningkatan risiko kematian dan acute kidney injury
(AKI) dibandingkan dengan kristaloid. Efek dari gelatin(koloid) kurang jelas, tetapi
lebih mahal dibanding kristaloid. Cairan hipotonik kurang efektif dalam
meningkatkan volume intravaskular. Survaving Sepsis juga menyarankan
penggunaan albumin untuk resusitasi pasien membutuhkan sejumlah besar
kristaloid (QE rendah)
(Malbrain, Ho & Wong, 2020)
GUIDELINES TERAPI CAIRAN PADA PASIEN COVID-19
International Fluid Academy (IFA)
Pengkajian dan
Pemantauan Resusitasi Pemeliharaan (Maintenance) cairan Fluid Creep

- Kaji keseimbangan - Gunakan kristaloid - Jangan berikan cairan tambahan - Semua sumber pemberian
cairan pasien saat - Jangan gunakan larutan koloid atau gelatin pada pasien yang makan dan cairan harus diperinci:
masukn RS dan setiap - Jangan menggunakan albumin pada tahap wal minumnya cukup kristaloid, koloid, produk
hari - Untuk pasien yang membutuhkan resusitasi: darah, nutrisi enteral dan
- Pengkajian kebutuhan o Identifikasi penyebab kekurangan cairan - Gunakan cairan seimbang (Mis. parenteral, medikasi IV, dan
cairan dan elektrolit, o Kaji adanya syok atau hipoperfusi glukosa 5%) asupan oral (air, teh, sup, dll)
menggunakan o Kaji fluid responsiveness
kombinasi clinical - Berikan bolus kristaloid seimbang 4mL/KgBB selama - Pada pasien yang membutuhkan - Dokumentasikan setiap
judgement, TTV, dan 10-15 menit cairan IV rutin saja, pemberian: elektrolit pekat yang
catatan atau medrek). - Kaji fluid responsiveness sebelum dan setelah o 25-30 mL/Kg/hari → air ditambahkan ke cairan
pemberian cairan denggan hemodinamik fungsional o sekitar 1 mmol / kg / hari → ataupun diberikan secara
- Pantau hasil lab urea (mis. Pulse pressure variation) potasium (K +) terpisah
dan elektrolik - Pantau MAP dan curah jantung o sekitar 1-1,5 mmol / kg /
(setidaknya per 24 o Inisiasi dini vasopressor: noradrenaline dosis hari → natrium (Na +) - Fluid creep didefinisikan
jam saat diberikan rendah 0,05 mcg/Kg/menit o sekitar 1 mmol / kg / hari → sebagai jumlah volume
resusitasi cairan) o Pertimbanggkan penambahan klorida (Cl-) elektrolit, volume kecil untuk
vasopresin/agripresin saat dosis noradrenaline o sekitar 50-100 g / hari (1- menjaga jalur vena tetap
- Kaji respon cairan melebihi 0,5 mcg/Kg/menit 1,5 g / kg / hari) → glukosa terbuka (salin atau glukosa
dengan cara cek curah - Kaji adanya cairan berlebih (mis. Naik 10% dari BB) hingga membatasi ketosis 5%) dan volume total yang
jantung (mis, USG dan o Mulai de-resusitasi jika memungkinkan kelaparan digunakan cairan yang
bioimpedance) o Ganti serum albumin menjadi sekitar 30g/L digubakan sebagai untuk
dengan albumin 20% - Jumlah asupan cairan melalui sumber medikasi.
o Gunakan terapi kombinasi diuretik: loop + lainnya harus dikurangi dari intake
sprinolactone + acetaolamide (saat BE>5) + cairan dari penyerapan dan nutrisi
indapamide (kasus hipernatremia) yaitu 1 cc/kg/jam.
o Pertimbangan ultrafiltration
(Malbrain, Ho
(Malbrain, Ho &
& Wong,
Wong, 2020)
202
Figure 1. Sample screenshot with results obtained via full body, mullifrequency bioele<:uical impedance analysis (B�I with touch iB device IMaltron, UK)
showing a volume excess
of 2.b litres and an increased ECW:ICW ratio of 0.963 indicating capillary leak. The patient's fluid composition is monitored with BIA separating intra-
“ Fluid therapy, either
too much or too little,
can adversely affect “
patient outcome
(Malbrain, Ho & Wong, 2020)
Kesimpulan

Meskipun bermasalah SDM, ketersediaan APD dan fasilitas dan sarana tidak
diragukan lagi merupakan hal yang penting dalam penanganan pandemi covid
19 ini, namun pengelolaan kebutuhan cairan pada pasien covid tidak dapat
diabaikan. Pasien dengan Coronavirus Disease (COVID-19) berisiko mengalami
kekurangan cairan tubuh, yang disebabkan oleh terjadi kebocoran plasma di
kapiler dan peningkatan suhu tubuh (demam). Pengelolaan mengenai
kebutuhan cairan pasien COVID-19 ini perlu mendapat perhatian dari Perawat,
agar tidak terjadi syok pada pasien yang bisa memperparah kondisi pasien
covid 19.
Referensi:

Contini, C., Di Nuzzo, M., Barp, N., Bonazza, A., De Giorgio, R., Tognon, M., & Rubino, S. (2020). The novel zoonotic COVID-19
pandemic: An expected global health concern. The Journal of Infection in Developing Countries, 14(03), 254-264.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the
life span. FA Davis.

Gues, M. (2020). Understanding the principles and aims of intravenous fluid therapy. Nursing standard. doi:
10.7748/ns.2020.e11459

Gugus Tugas COVID-19. (2020). Pedoman penanganan cepat medis dan kesehatan masyarakat COVID-19 di Indonesia. Jakarta

Guo, Y. R., Cao, Q. D., Hong, Z. S., Tan, Y. Y., Chen, S. D., Jin, H. J., ... & Yan, Y. (2020). The origin, transmission and clinical therapies
on coronavirus disease 2019 (COVID-19) outbreak–an update on the status. Military Medical Research, 7(1), 1-10.

Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., ... & Cheng, Z. (2020). Clinical features of patients infected with 2019 novel
coronavirus in Wuhan, China. The lancet, 395(10223), 497-506.

Malbrain, M. L.N.G., Ho, S., Wong, A. (2020). COVID-19 challenges. ICU Management & Practice, 20(1), 80-85.

Silverthron, D. U. (2010). Human physiology: An integrated approach. 5th ed. Sansome St: Pearson Education.

Yuki, K., Fujiogi, M., & Koutsogiannaki, S. (2020). COVID-19 pathophysiology: A review. Clinical Immunology, 108427.

Covid19.go.id
TERIMA KASIH