BED 3/ Tn. AGUS RIADI / 50thn/ 75kg/ 175cm/ BMI 24.5/ hp ICU 6/HO 17 Subjective & Objective Assessment S) Sesak (+) pasien bisa tidur B1: Clear, spontan RR 25-30x/menit, SpO2 89-93 % dengan HFNC dan NRM Fio2/flow 90/60 81/15 B2: TD 145/79 mmHg, HR 90-100x/m B3: CM E4M6V5 B4: BAK + via DC, UO 2400 cc/24jam, 100 cc/jam, BC -313,2 cc/24jam B5: BU (+) ma/mi via oral B6: Temp 36.8⁰C Pneumonia Covid-19 terkonfirmasi derajat kritis HAP DM tipe 2 Susp PE Hipokalemia Therapy F: NS 1000 cc/24 jam, Inf Wida KN 2 500cc/24jam, ma/mi via oral cc/24 jam A: S: T: Heparin 1200 cc/jam H: Head up U: Inj omeprazole 2x40mg G: GDS berkala Inj. Novorapid 3x8iu Injeksi: 04/3/2021 Hb 13,9 Leu 13.500 Tro 348.000 Pt/apt 10/52,7 Gds 160 LDH 1273 Alb 3,2 BilTot/Dir/Ind 1,25/0,81/0,44 Ot/pt 80/70 Ur/cr 21/0,71 Na/K/Cl 137/3,1/107 AGD pH 7,412 PO2 58 pCO2 28,7 HCO3 18,4 BE -6 SpO2 92 FiO2 100 p/f 66,6 05/3/2021 Pt/apt 13,1/135,1 AGD pH 7,417 PO2 59 pCO2 28,9 HCO3 18,7 BE -6 SpO2 92 FiO2 90 p/f 65,5 06/3/2021 Hb 13,1 Leu 18.100 Tro 479.000 Pt/apt 10.8/30,5 Gds 103 Alb 2.9 BilTot/Dir/Ind 1,25/0,56/0,56 Ot/pt 132/105 Ur/cr 30/0,89 AGD pH 7,450 PO2 37 pCO2 29,7 HCO3 20,8 BE -3 SpO2 97 FiO2 80 p/f 46.25 07/03/2021 Na/K/Cl 131/4.2/107 08/3/2021 Pt/apt 14,5/58,0 Na/K/Cl 136/4.1/107 AGD pH 7,445 PO2 52.0 pCO2 24.8 HCO3 24.0 BE 0.0 SpO2 89 FiO2 90 p/f 57.7 09/3/2021 Hb 13,3 Leu 14.200 Tro 554.000 Pt/apt 13.9/37,0 Gds 103 Alb 2.8 BilTot/Dir/Ind 0.71/0.42/0.29 Ot/pt 35/54 Ur/cr 28/0,74 Na/K/Cl 131/4.2/103 AGD pH 7,437 PO2 60 pCO2 32.9 HCO3 22.3 BE -2 SpO2 93 FiO2 90 p/f 66.6 Swab + (26/2/2021) Planning: Evaluasi EKG, AGD, Pt/Aptt per hari • Evaluasi GDS, Urin Output + Balance Cairan /shift • Cek Lab protocol covid/ 12-032021 • Evaluasi CXR /3 hari (09-032021) tunggu hasil • Evaluasi hemodinamik dan tanda2 perdarahan • Latihan pernapasan/Tripod position • Motivasi mobilisasi aktif • KU/KD/KS 5/3/2021 hasil 15/3/2021 • Post plasma konvalescens 2x (67/3/2021) Drip Resfar 25cc/24jam Inj Gentamisin 2x 160 mg (H6) Inj Ceftazidine 3x2 gr (H6) Inj Vit C 2x500 mg Inj ondansetron 3x4mg Dexametasone 1x6 mg (H6) Inj remdesivir 1x100 mg (H6) Inj Cernivit 1x1 Per Oral Cholcisine 2x0,5mg (H 6) Zinc 1x20mg L-Bio 2x1 sach Vit.D 1x5000 iu HP pro 3x2 tab KSR 3x 600 mg Sancoidan 3x1 Sambiloto 4x2 caps VIP Albumin 3x2 caps Invermectin 1x12mg (H2)