HCU

09-11/04/2019 Move room to HCU - Potential respiratory failure - IVFD D13% 580/18,8ml/hour + D40% 78ml +
03.00 S: receive patient from C1L1. general condition of the patient: shortness - Bronchopneumonia NaCl 3% (2meq) 25ml + KCl otsu (2meq) 12,85ml
Day : 20-22 of breath (+), fever (-), Watery diarrhea (-), vomitus (-) - DE: Acyanotic congenital heart disease + Ca glukonas (0,5meq) 6,91ml (GIR 7,48; Osm
Day HCU : 1 O: KU : awake DA: VSD Ø 7-8mm, ASD II Ø 5mm 803; BUN 380)
HR : 180x/minute N : regular, adequate DF: heart failure Ross III - Ivelip 20% 70/3ml/hour
RR : 36x/minute t : 36,8oC - Anemia microcytic normokromik (8.1) - Amiparen 10% 56/2,4ml/hour
SpO2 : 100% TD : 112/73 mmHg (P95+12) - Severe acute malnutrition, mesocephal - Drip furosemide 2mg/kg/day ~ 10mg/day
R: symmetric, retraction (+) epigastrial, subcostal - Acute diarrhea with mild dehydration (corrective) - Drip dobutamin 5mcg/kg/minute, gradual titration
vesicular breath sound +/+ +/+ - Imbalance electrolytes (hyponatremia, 10mg/kg/minute
AS ronchi +/+ +/+ hypochloremia) - Inj. fosfomycin 600mg/12hour (H5)
AS wheezing +/+ +/+ - Inj. paracetamol 60mg/4-6hour (t > 38oC)
I: fever (+) Per Oral:
C: shock (-) - Digoxin 0,025mg/12hour
Cor: Heart sound I normal, heart sound II wide fixed split, murmur (+) - Captopril 2,5mg/8hour
pansystolic grade III/6 PM di SIC IV LPSS, gallop (-), thrill (-)
H: haemorrhage (-) PROGRAM:
- Nebulization Ventolin 1 respul + NaCl 0,9% 2ml
continue with pulmicort 1 respul + NaCl 0,9%
2ml/12hour
- Chest x ray imaging on site
- PRC tranfusion (25cc; 50cc; 50cc
- Evaluation for distress respiratory, dehydration sign

Day 2 S: fever, desaturation, respiratory distress - Probable respiratory failure - Intubatated with ET size 4,level 12 cm on Jackson
reese
- Adrenalin 0.1mg/ kg/ min
O: Somnolen - Chest x-ray evaluation
BP: 88/40 mmHg t: 38.2 C - BGA
HR: 190 x/m
RR: 61x/m

Day 3 Transfered to PICU