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S
Keluhan

O
Status
B1 (Breath) : vesikuler (+/+),

P
Penatalaksanaan

17/02/2016

rhonki(-/-), Wheezing (-/-). RR :

Malaria

- O 2 10 L

Pkl. 07.00

28x/menit. Terpasang nasal kanul

Cerebral

- Oral hygiene 2x/hri

10L/mnit.
-

A
Assesment

- Chest terapi 2x/hari

Demam (+),
sesak (+),

- IVFD aminofluid
B2(Blood): BJI+II vesikuler, mur-

1000cc/hari

mur (-/-) , Gallop(-/-), Hr :

- Ceftriaxone 1g/hri

95x/menit .

- Ranitidine 1g/hri
- Drip Kina 1amp/8jam

B3 (Brain) : KU

:Tampak

Sakit Berat
KS: Somnolen, GCS8 E3M4V1

- Artesunat 1amp/hari
IM
- Diet sonde 6x250cc

B4(Bladder) : Intake : 2800, output

2300
BC : +500
B5Bowel) : Bu (+). Perut datar,
lemas.
B6 (Bone) : Dbn

18/02/2016

B1 (Breath) : vesikuler (+/+),

Pkl. 07.00

rhonki(-/-), Wheezing (-/-). RR :

- Oral hygiene 2x/hri

28x/menit. Terpasang nasal kanul

- IVFD aminofluid

Penurunan

10L/mnit.

kesadaran,
Demam (+),

Malaria Cerebri - O 2 10 L

1000cc/hari
- Ceftriaxone 1g/hri

B2(Blood): BJI+II vesikuler, mur-

- Artem 1amp IM

muntah (-).

mur (-/-) , Gallop(-/-), Hr :

95x/menit ,TD 110/70

- Omeprazole vial /
12jam
- Farmadol drip (prn)

B3 (Brain) : KU

:Tampak

Sakit Berat

- PCT 4x 500mg
- Diet sonde 6x250cc

KS: Somnolen, GCS8 E3M4V1

B4(Bladder) : Intake : 2800, output
2100
BC : +700
B5Bowel) : Bu (+). Perut datar,
lemas.
B6 (Bone) : Dbn
- O 2 10 L
19/02/2016

B1 (Breath) : vesikuler (+/+),

Pkl. 07.00

rhonki(-/-), Wheezing (-/-). RR :

- IVFD aminofluid

28x/menit. Terpasang nasal kanul

1000cc/hari

Penurunan

10L/mnit, T : 37,6OC.

Malaria Cerebri - Oral hygiene 2x/hri

- Ceftriaxone 1g/hri

kesadaran,

- Artem 1amp IM

demam(+),

B2(Blood): BJI+II vesikuler, mur-

muntah (+)

mur (-/-) , Gallop(-/-), Hr :

dari Ngt

95x/menit .

- Omeprazole vial /
12jam
- Farmadol drip (prn)

200cc

- PCT 4x 500mg
B3 (Brain) : KU

:Tampak

Sakit Berat
KS: Somnolen, GCS8 E3M4V1

- Metronidazole
1fls/8jam
- Nebu
combivent:fluxetin /

B4(Bladder) : Intake : 2800, output

2300
BC : +500
B5Bowel) : Bu (+). Perut buncit,
lemas.

12jam
- Diet sonde 6x250cc

B6 (Bone) : Dbn