CUE AND CLUE Problem List Initial Planning Planning Planning

Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 1. SoB + infiltrat 1.1 TB Pulmo K/S sputum Non Pharmacology: Plan Monitoring:
- Dyspneu sunce 1 week ago, intermiiten, worsen in the
last 3 days. pulmo with smear gr, - Oxygenation with target SpO2 • Vital sign
- Cough (+) since 10 days before admitted secondary genexpert >95% • Symptom: Dyspneu, cough
- Fatigue (+)
- night sweats (+) since the last 10 days infection CAP TCM Pharmacology
- Decrease of body weight - Azitromisin 1x500 mg
1.2 Massa Paru - Inj. Ceftriaxon 1 g/ 12 hour Plan Education:
dd - NAC 3x200 mg • Educate that the condition
Mediastinum and what its aetiology of
Objective Laboratory results: the disease
GCS E4V5M6 Lab 11/05/24 Bhayangkara • Educte to family adn
BP: 157/100 mmHg Hospital patient about the planning
HR : 90 x/minute Leukosit 10.700
RR : 22 x/ minute N% 71 therapy
T : 36.9C L% 14 • Educate the family about
SpO2 : 90-->98 % NK 4 lpm Monosit% 8 the prognosis of the
Pulmo: Breath sounds CXR 03/05/24 Bayangkara disease
(BvVV/BvBvV), rough wet crackles Hospital
(+--/++-)* wheezing (---/---) Infiltrates and consolidation of the
upper middle field of the left lung
Scoring: suggest a picture of pulmonary TB
ATS Score multilobular infiltrate, and pneumonia
uremia
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 2. HF st C FC III + VES Non Pharmacology: Plan Monitoring:

- DOA (+) - Oxygenation with target SpO2 • Vital sign
- PND (-) Occasional
- Orthopneu (-) >95% • Symptom: Dyspneu
Pharmacology
• Amlodipin 10 mg-0-0
• Candesartan 0-0-16 mg Plan Education:
• Educate that the condition
and what its aetiology of
Objective Laboratory results: the disease
GCS E4V5M6 EKG on 11/5/24 • Educte to family adn
BP: 157/100 mmHg Sinus rhythm HR 86 bpm, T patient about the planning
HR : 90 x/minute inverted V2 V3, VES Occasional
RR : 22 x/ minute therapy
T : 36.9C CXR 03/05/24 Bayangkara • Educate the family about
SpO2 : 90-->98 % NK 4 lpm Hospital the prognosis of the
LV LA cardiomegaly, elongation of
Cor: Murmur (-), regular heart the aortic arch disease
song
Extermity: Edema (-/-)
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 3. Melena non 3.1 PUD USG Non Pharmacology: Plan Monitoring:
- Melena (+) since 3 days ago, with frequency 2x/day
- Nausea et vomitus (+) variceal 3.2 Gastropathy Abdomen • Soft DM renal diet 1500 • Vital sign
- Low apetite (-) NSAID kcal/day • Symptom: Melena
- Epigastric pain (+) • Low Salt diet < 5 g/day
- Consumption of analgesic (+) FL and
• Protein Diet 1-1.2
benzidine g/KgBW/day
test Plan Education:
Pharmacology • Educate that the condition
OMD • Drip Lansoprazole bolus 60 and what its aetiology of
mg continued 6 mg/hour the disease
Objective Laboratory results:
• Inj. Metoclopramide 10 mg/
GCS E4V5M6 Lab 11/05/24 Bhayangkara
8 hours • Educte to family adn
BP: 157/100 mmHg Hospital patient about the planning
HR : 90 x/minute Leukosit 10.700 • Sucralfate Syr 3x 15 cc
RR : 22 x/ minute N% 71 therapy
T : 36.9C L% 14 • Educate the family about
SpO2 : 90-->98 % NK 4 lpm Monosit% 8 the prognosis of the
Cor: Murmur (-), regular heart Lab 11/05/24 RSUD Ulin disease
song PT 12.1/ APTT 22.1/ INR 1.13 • Educate to patient and
Extermity: Edema (-/-) SGOT/PT 13/20 family about not to take
CXR 03/05/24 Bayangkara NSAID regularely
Hospital
LV LA cardiomegaly, elongation of
the aortic arch
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 4. Severe Anemia 4.1 Occult peripheral Non Pharmacology: Plan Monitoring:
- Weakness (+)
- Pale (+) blood loss blood • Soft DM renal diet 1500 • Vital sign
- Melena (+) morphology kcal/day • Symptom: Pale, weakness
4.2 AIHA before • Low Salt diet < 5 g/day
• Protein Diet 1-1.2
tranfusion g/KgBW/day
Plan Education:
Retikulosit Pharmacology • Educate that the condition
• (10- 5.5)x 4x 60 kg= 1080 cc and what its aetiology of
Leukodepleted PRC the disease
Objective Laboratory results: transfusion 1 kolf / 24 hours
GCS E4V5M6 Crossmatched 11/5/24
(a total of 3 kolf) • Educte to family adn
BP: 157/100 mmHg Major negative patient about the planning
HR : 90 x/minute Minors +2 • As. Folat 1x5 mg
RR : 22 x/ minute Autocontrol +2 therapy
T : 36.9C DCT +2 • Educate the family about
SpO2 : 90-->98 % NK 4 lpm the prognosis of the
Lab 11/05/24 Bayangkara
Eyes: Pale conjungtiva (-) Hospital disease
Hb 5.3
CXR 03/05/24 Bayangkara
Hospital
LV LA cardiomegaly, elongation of
the aortic arch
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 5. Anorexia geriatric 5.1 rt Infection Non Pharmacology: Plan Monitoring:
- Nausea et vomitus (+)
- Epigastric pain (+) without dehydration 5.2 Gastropathy • Soft DM renal diet 1500 • Vital sign
- Low of apetite (+) DM kcal/day • Symptom: nausea et
- Decrease of body weight (+) • Low Salt diet < 5 g/day
- History of DM (+) 5.3 rt no.3 vomitus
• Protein Diet 1-1.2
g/KgBW/day • Recall diet/day
Pharmacology
• IVFD NaCl 500 cc/24 hour Plan Education:
Objective Laboratory results:
• Inj. Metoclopramide 10 mg/ • Educate that the condition
GCS E4V5M6 Crossmatched 11/5/24
8 hours and what its aetiology of
BP: 157/100 mmHg Major negative • Sucralfate Syr 3x 15 cc
HR : 90 x/minute Minors +2
the disease
RR : 22 x/ minute Autocontrol +2 • Educte to family adn
T : 36.9C DCT +2 patient about the planning
SpO2 : 90-->98 % NK 4 lpm therapy
Lab 11/05/24 Bayangkara
Abdomen: BU (+), increased Hospital
tympanic, supple, epigastric Hb 5.3
tenderness
CXR 03/05/24 Bayangkara
Scoring: Hospital
Who dehidrasi score : 6 ( without LV LA cardiomegaly, elongation of
dehydration) the aortic arch
 CUE AND CLUE
Ms. S/66 y.o
- Nausea et vomitus (+)
- Epigastric pain (+)
- Low of apetite (+)
- Decrease of body weight (+)
- History of DM (+)
Objective
GCS E4V5M6
BP: 157/100 mmHg
HR : 90 x/minute
RR : 22 x/ minute
T : 36.9C
SpO2 : 90-->98 % NK 4 lpm
GDS 211 mg/dL
Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring
6. DM type II Non Pharmacology: Plan Monitoring:
hiperglikemic state • Soft DM renal diet 1500 • Vital sign
kcal/day • Check GDP GD2PP/day
non critically ill • Low Salt diet < 5 g/day
• Protein Diet 1-1.2
• Check GDS/ pre meal
g/KgBW/day
Plan Education:
Pharmacology • Educate that the condition
• IInj. Levemir 1x 8 IU and what its aetiology of
Laboratory results:
• Inj. Novorapid 3x4 iu the disease
Lab 11/05/24 RSUD Ulin • Educte to family adn
GDS 208 patient about the planning
Lab 11/05/24 Bayangkara therapy
Hospital • Educate the family about
GDS 425--> 359 the prognosis of the
disease
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 7. AKI stage III dd 7.1 Acute : Non Pharmacology: Plan Monitoring:
- Urinate frequency 5-6x and change diapers 2-3x with
full condition. ACKD with asidosis Infection • Soft DM renal diet 1500 • Vital sign
- History of HD (-), CKD (-) kcal/day • Check for Ur/cr /day
metabolik • Low Salt diet < 5 g/day
7.2 Chronic : • Evaluates AGD
• Protein Diet 1-1.2
DKD, HTN g/KgBW/day • Monitoring of UOP and BC
targets is balanced
Pharmacology
• Folic acid 1x5mg Plan Education:
Objective Laboratory results:
• Inj. Ceftriaxone 1gr/ 12 • Educate that the condition
GCS E4V5M6 Lab 11/05/24 Bayangkara
hours and what its aetiology of
BP: 157/100 mmHg Hospital the disease
HR : 90 x/minute Ureum 208 /Cr 5.8 Consult to nephrology
RR : 22 x/ minute eGFR 8 / BUN:Cr 16 duvusuin • Educte to family adn
T : 36.9C patient about the planning
SpO2 : 90-->98 % NK 4 lpm AGD Results 11/5/24 therapy
UOP : 1400 cc/ 12 hours/Diuresis : PH 7.312/ PCO2 22.9
1.9 cc /KgBB/hour PO2 88/ HCO3 11.7 • Educate the family about
P/F Ratio 419 the prognosis of the
Abdomen: Suprapubic tenderness Effects of partially compensated disease
(+) metabolic acidosis
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 8. HT st II Non Pharmacology: Plan Monitoring:

- History of HT (+) since 3 years ago.
• Soft DM renal diet 1500 • Vital sign: BP
kcal/day
• Low Salt diet < 5 g/day Plan Education:
• Protein Diet 1-1.2
g/KgBW/day • Educate that the condition
and what its aetiology of
the disease
Pharmacology • Educte to family adn
Objective
• Amlodipin 10 mg-0-0 patient about the planning
GCS E4V5M6 • Candesartan 0-0-16 mg therapy
BP: 157/100 mmHg
HR : 90 x/minute • Educate the family about
RR : 22 x/ minute the prognosis of the
T : 36.9C disease
SpO2 : 90-->98 % NK 4 lpm
Cor: Murmur (-), regular heart
sound
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 9. Trombositosis dt Non Pharmacology: Plan Monitoring:

- Febris (-)
- Cough (+) reaktif • Soft DM renal diet 1500 • Vital sign: BP
- Dyspneu (+) kcal/day
• Low Salt diet < 5 g/day Plan Education:
• Protein Diet 1-1.2
g/KgBW/day • Educate that the condition
and what its aetiology of
the disease
Pharmacology • Educte to family adn
- Azitromisin 1x500 mg patient about the planning
Objective Lab 11/05/24 Bayangkara - Inj. Ceftriaxon 1 g/ 12 hour
GCS E4V5M6 Hospital therapy
BP: 157/100 mmHg Trombosit 544.000
HR : 90 x/minute • Educate the family about
RR : 22 x/ minute the prognosis of the
T : 36.9C disease
SpO2 : 90-->98 % NK 4 lpm
Cor: Murmur (-), regular heart
sound
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 10. Clinically OA Rontgen Non Pharmacology: Plan Monitoring:
- knee pain (+)
- Swelling (-) genu bilateral Genu • Soft DM renal diet 1500 • Vital sign
Bilateral kcal/day • Symptom
• Low Salt diet < 5 g/day
• Protein Diet 1-1.2
g/KgBW/day Plan Education:
• Educate that the condition
and what its aetiology of
Pharmacology the disease
Inj. Paracetamol 1 g/ 8 hour • Educte to family adn
Objective Lab 11/05/24 Bayangkara
GCS E4V5M6 Hospital patient about the planning
BP: 157/100 mmHg Trombosit 544.000 therapy
HR : 90 x/minute
RR : 22 x/ minute • Educate the family about
T : 36.9C the prognosis of the
SpO2 : 90-->98 % NK 4 lpm disease
Bilateral a/r genue localis status
Look : Swelling (-) deformity (-)
Feel: warm (-), tenderness (-),
crepitation (+/+)
Move : Limited ROM
 CUE AND CLUE Problem List Initial Planning Planning Planning
Diagnosis Diagnosis Therapy monitoring

Ms. S/66 y.o 11. Geriatric Non Pharmacology: Plan Monitoring:

- Weakness (+)
problem (Infection, • Soft DM renal diet 1500 • Vital sign
kcal/day • Symptom
inanisi, • Low Salt diet < 5 g/day
imunodefisiensi, • Protein Diet 1-1.2
instability, g/KgBW/day Plan Education:
immobilisasi) • Educate that the condition
Join care with geriatric division and what its aetiology of
the disease
Objective Lab 11/05/24 Bayangkara • Educte to family adn
GCS E4V5M6 Hospital patient about the planning
BP: 157/100 mmHg Trombosit 544.000 therapy
HR : 90 x/minute
RR : 22 x/ minute • Educate the family about
T : 36.9C the prognosis of the
SpO2 : 90-->98 % NK 4 lpm disease
Scoring
- Frailty: 3 (Frail)
- ADL: 10 (moderate dependence)
- IADL: 6
- Geriatric depression: 1 (no
depressive disorder)
- MNA: short form: 12 (no risk of
malnutrition)
- Norton: 14 (possible moderate
risk of decubitus ulcers)
- Risk Fall: 2 (High risk)