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    Laporan Dinas Malam-Iva-1

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    yuni hunaini
    1. The document provides a report from the night shift service at the hospital on November 16, 2021. 2. It includes 4 patients being treated overnight, providing their status, treatment plan and medications. 3. The night team consisted of nurses Nurul, Roslin and Bagus, overseen by the attending physician Dr. Sabana.

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    Laporan Dinas Malam-Iva-1

    Uploaded by

    yuni hunaini
    43 views5 pages
    1. The document provides a report from the night shift service at the hospital on November 16, 2021. 2. It includes 4 patients being treated overnight, providing their status, treatment plan and medications. 3. The night team consisted of nurses Nurul, Roslin and Bagus, overseen by the attending physician Dr. Sabana.

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    LAPORAN DINAS MALAM-IVA-1

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    1. The document provides a report from the night shift service at the hospital on November 16, 2021. 2. It includes 4 patients being treated overnight, providing their status, treatment plan and medications. 3. The night team consisted of nurses Nurul, Roslin and Bagus, overseen by the attending physician Dr. Sabana.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    43 views5 pages

    Laporan Dinas Malam-Iva-1

    Uploaded by

    yuni hunaini
    1. The document provides a report from the night shift service at the hospital on November 16, 2021. 2. It includes 4 patients being treated overnight, providing their status, treatment plan and medications. 3. The night team consisted of nurses Nurul, Roslin and Bagus, overseen by the attending physician Dr. Sabana.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    B LAPORAN DINAS MALAM

    SELASA, 16 NOVEMBER 2021

    N BED Nama Pasien SBAR Rencana Antibiotik


    O

    1 KMR 3 Tn.M.Gani S: perawatan H-0 Infus: Meropenem (1)


    BED 4 00.28.26.35 K/u berat,CM, O2 3lpm/NK  Kabiven/24 jam
    09-09-1979 D/C(+), NGT(+)  RL/24jam

    DPJP: bedah B: post op laparatomy APR a.i adeno Ca Instruksi post op:
    digestive Recti  Puasa NGT alirkan
     Cek DPL post op, jika Hb <10,
    PJ: Br. Sofyan A transfuse PRC (Hb post op 11 gr/dl)
    TD:85/74 mmhg  Hitung produksi drain (ada 2 drain, 1
    OSB dari IKW HR: 88 x/mnt vaccum, 1 non vaccum)
    jam 15.00 RR: 18 x/mnt  TH PA jaringan (16/11/21)
    S : 36,7  GV luka H+2 by nurse
    Sat 100%  Drain kiri vacuum: 400cc
    Drain kanan:200cc
    R
    F: puasa
    A: PCT
    S: -
    T: -
    H: 30
    U: OMZ
    G: GDS/hr

    BC: +774,5cc
    BD: 0,3cc/kgbb/jam

    2 KMR 1 Ny. Rati S: Perawatan hr 10 IVFD : Meropenem(4)


    BED 4 00286117 K/U tsb,kes .Somnolent ,On Venti PS10 1. RL/24 jam Stop
    01 Juli 1940 PEEP5 FIO240% Amikasin(1)
    NGT (+) ,D/C (+) Urine (+) , EVD (+)
    DPJP : RENCANA :
    B.Syaraf B : PO Craniotomie Ecc SH  Obs Vital sign
    Raber :  EVD sejajar dengan kepala
    IPD A:  EVD jangan smp tercabut
    Kardio TD: 154/72 mmhg  Th/ inhalasi Ventolin 3x/ hr
    URM RR: 25x/mnt  Lapor hasil kultur sputum (+), jawab(-)
    HR :114 x/mnt  R/Traceostomy,besok,IC(+) klg acc
    PJ : Zr.nur + SH : 37,6  T/hsl Exp Ro.thorax tgl 13-11-21
    Br.Nurul Sat : 95 %  Tracheostomy di OKB, DO(+) SIO(+)
    SITA(+)
    R:  Co anestesi (+), by dr.Rafidya, jawab(+),
    F : MCRS 3x250 cc, MC Peptisol 3x250 cc acc op, puasa 8 jam pre-op
    A : Tramadol  Px Swab antigen,hsl negative
    S:-  Intruksi dr Fahrul:
    T :- -meropenem stop
    H : 30 - ganti amikasin 1x1500
    U : OMZ
    G : GDS / Hr

    BC : - 1226 cc
    BD : 2,1cc/kgbb/jam
    BK :-34,6cc

    3 KMR 3 Ny. Rasmah S: perawatan H-0 Infus: ceftriaxon


    BED 2 00.27.99.54 K/u berat, DPO, on venti Mode VC RR12  RL/8jam
    05-03-1973 PEEP5 TV500 FIO240% Sat 100%  Icunez 3cc/jam
    D/C(+), NGT(+), Drain(+)  Recopol 3cc/jam
    DPJP: bedah
    syaraf B: post op craniotomy tumor removal a.i Instruksi post op
    multiple meningioma
    PJ: Br.Bagus  Weaning & extube segera
    A  Early feeding
    OSB dari Soka TD: 124/73 mmhg  Posisi duduk tegak
    jam 15.30 HR: 46 x/mnt  Transfuse PRC 2 bag selesai jam 19.00.
    RR: 13 x/mnt  Px DPL post transfuse,Elek,Gds- T/
    S : 36 Hasil
    SP02:100%

    R
    F: diit bertahap
    A: Icunez
    S: Recopol
    T: -
    H: 30
    U: OMZ
    G: GDS/hr

    BC: -496cc
    BD: 1,4 cc/kgbb/jam

    4 KMR 1 Ny, Ria susanti S:Perawatan hr 0 INFUSRL:D5% 2:1 Ceftriaxone(1)


    BED 2 00286806 k/u tsb,kesd DPO, on Venti mode VC,
    RR12,PEEP 5,TV 400,FI02 50% SP02 RENCANA:
    4-5-1982 100%  R/ PX DPL PT,E;ek,alb,gds jam
    DC(+) NGT(+) 09.00
    DPJP:Obgyn  Diet sesuai bising usus
    B:PO Laparatomy Histerektomi subtotal  Balance cairan seimbang
    PJ: Zr. Roslin Masalah:  T/ hasil pa jaringan
    1 Gang,pola nafas  Perdarahan di ok 1500 cc, sudah
    OSB dari OKD 2. Gang bersihan jln nafas masuk prc3 kantong,ffp 2 kantong
    jam 05.00 3. Nyeri selesai jam 04,00
    4. Resiko perdarahan  Target HB > 8
    5. Intoleransi ADL  Ca gluconas 1 amp(+)

    A:
    TD:90/79mmhg
    HR:108 x/mnt
    RR:15x/mnt
    S : 36
    SP02:100%

    R:
    F:Puasa
    A:fentanyl
    S:Milos
    T:
    H:30
    U:OMZ
    G:Gds/hr

    BC: cc
    BD: cc/kgbb/j

    Pasien Awal :3
    Ventilator : 3
    Tpiece :-
    NK :1
    NRM :-
    CVC :-
    S.Mask :-
    Pasien Pindah :
    Pasien PAPS :-
    Pasien baru :1
    Pasien Pulang :-
    Pasien meninggal: -
    Pesanan: -
    Total Pasien : 4

    Dinas Malam: IVA dkk

    Dokter jaga : dr.Sabana

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