mekong minggu 3
DESCRIPTION
mekongTRANSCRIPT
![Page 1: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/1.jpg)
Morning Report
20 Januari 2016
![Page 2: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/2.jpg)
laki-laki, 9 Thn, 20 kg
• KU : luka bakar pada kepala, dada, dan kedua tangan
• Telaah : Hal ini telah dialami os kurang lebih 2 bulan ini , os mengaku terkena luka bakar akibat ledakan lampu minyak. Os sebelumnya telah berobat di RS Riau, kemudian telah dilakukan tindakan cangkok kulit, di RS Riau. Os saat ini mengeluh nyeri seluruh badan yang terkena luka bakar.
• Mual (-), muntah (-). Riwayat BAK (+) N, BAB (+) N• RPT : -• RPO : -
![Page 3: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/3.jpg)
3TIME SEQUENCE
• Pasien masuk RSUPM jam 13.47 WIB
• Konsul anestesi pkl 17.00WIB• Acc tindakan anestesi 20.00 wib
• Operasi Pkl: 12.00 WIB
![Page 4: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/4.jpg)
4Pemeriksaan Fisik Tanggal 20-01-2016
• B1 : Airway : clear,snoring(-),gurgling(-),crowing (-), RR : 20 x/i, SP: vesikuler, ST: -/-, Buka mulut : 3 jari, , Mallampati : 1 , GL : bebas. Riw. Asma/Sesak/Batuk/Alergi: -/-/-/-
• B2 : CRT : < 2 detik, Akral : hangat, T/V: kuat / cukup, TD: 110 / 60 mmHg, HR: 130x/i, reguler, Temp: 37,2 0 C
• B3 : Sens : CM, pupil: isokor, Ø 3mm/3mm, RC: + / +.• B4 : Kateter urine (+), residu:-, warna : kuning• B5 : Abdomen: soepel , peristaltik (+), mual (-), muntah (-). MMT jam
15.00 WIB (20/01/2016)• B6 : Oedem (-), fraktur (-)
![Page 5: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/5.jpg)
LABORATORIUM
- Hb/ Ht/ L/ T : 10,1 / 30,6/ 10.700 / 372.000- pT/ INR / APTT : 15,0(15,5)/ 1,19 / 32,3 (35,4) - KGD AdR : 91,00 mg/ dl- Ur/Cr : 16/ 0,57- Na/K/Cl : 131 / 3,60/ 106- Albmin : 2,51
![Page 6: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/6.jpg)
6Penanganan di Ruangan
•O2 ½ l/I (k/p)•IVFD D5% NaCl 0,45% s/s RL 50 gtt/I (mikro)•IVFD Aminofusin 5%•Inj ceftriaxon 1 g /12jam•Inj. Ranitidine 20 mg /12 jam•Nistatin drops 4x2 ml•Paracetamol 4x250 mg•Diet SV 100 cc/3j/NGT + ekstra putih telur 6 butir
![Page 7: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/7.jpg)
Pemeriksaan Fisik di KBE
• B1 : Airway : clear,snoring(-),gurgling(-),crowing (-), RR : 20 x/i, SP: vesikuler, ST: -/-, Buka mulut : 3 jari, , Mallampati : 1 , GL : bebas. Riw. Asma/Sesak/Batuk/Alergi: -/-/-/-
• B2 : CRT : < 2 detik, Akral : hangat, T/V: kuat / cukup, TD: 110 / 70 mmHg, HR: 130x/i, reguler, Temp: 36,9 0 C
• B3 : Sens : CM, pupil: isokor, Ø 3mm/3mm, RC: + / +.• B4 : Kateter urine (+), residu:-, warna : kuning• B5 : Abdomen: soepel , peristaltik (+), mual (-), muntah (-). • B6 : Oedem (-), fraktur (-)
![Page 8: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/8.jpg)
8Diagnosa : Flame Burn gr II A- B/ 35%
• Tindakan : Debridement• PS ASA : II• Anestesi : GA-TIVA• Posisi : Supine
![Page 9: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/9.jpg)
9
Problem ListMasalah Pemecahan
Preoperasi:
•Nyeri
•Infeksi
•Pasien Anak
•Pasien Anak rentan hipotermia
• Beri analgetik
• Beri antibiotic
• Perbedaan fisiologis dan anatomi • Persiapan alat lengkap sesuai ukuran, obat sesuai
dosis dan peralatan emergensi• Sulit untuk akses venapastikan akses vena
cadangan tersedia .
• Siapkan blanket penghangat, dan hangatkan cairan, serta soft band
![Page 10: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/10.jpg)
10
Problem List
Masalah PemecahanDurante op:• Pasien dengan distensi abdomen
•Resiko perdarahan Hitung MABL (Maximum Allowable Blood Loss)
Post operasi: • Nyeri post op• Infeksi post op
• Pasang NGT untuk dekompresi,
MABL = (Ht awal – Ht target) x BB x 90 ml Ht rata2
= (37-34) x 27 x 80 35,5 = 182,53 ccEBV = 70 x 20 = 1400 cc
• Analgetik • Antibiotik
![Page 11: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/11.jpg)
11Persiapan Suction dan cairan hangat
![Page 12: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/12.jpg)
Durante Operasi
![Page 13: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/13.jpg)
13Durante
![Page 14: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/14.jpg)
Durante Operasi
• Lama operasi 40 menit• TD : 100-110/60-70 mmHg• HR : 130 - 140 x/i• SpO2: 99 %-100 %Balance Cairan• Pre op : RL 500 cc• Durante op : RL 250 cc • Perdarahan + 75cc• UOP = 400 cc
![Page 15: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/15.jpg)
15
![Page 16: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/16.jpg)
16Post Op
![Page 17: Mekong Minggu 3](https://reader031.vdocuments.net/reader031/viewer/2022020103/577c81ee1a28abe054aebd07/html5/thumbnails/17.jpg)
17
T E R I M A K A S I HTIM JAGA